Introduction: Our non-myeloablative transplants for early stage disease program started in 2000 for breast cancer and recommends treatment by combined modalities consisting of intensive or dose dense induction, an autologous transplant strategy and a non-myeloablative reduced intensity conditioning transplant (

Blood 2001; 98 (suppl 1): 5241, 5242
). In myeloma aggressive treatment from diagnosis has rarely been practised. Steroids with other low-dosed agents have been the standard for years and resulted in substantial mortality. The reason has been that the majority of patients are over 60 years at diagnosis of the disease (80% of women, 75% of males); myeloma start to reveal themselves around 40 years.

Methods: Several databases were searched to provide insight in the matter.

Results: A medline search on dose dense and myeloma showed no articles. Standard treatment in myeloma (melphalan and prednison or VAD) induce 6-10% (complete) responses; the newer agents thalidomide or bortezomib in combination with other agents induce 12 to 16% (complete) response, but the agents are quiet toxic.

Standard CHOP in myeloma has been reported to induce 60 to 65% partial response with very low toxicity (

Nippon Ronen Igakkai Zasshi 1991;28(4):504–508
). CHOP-14 is well tolerated in older lymphoma patients and should be evaluated in myeloma. Two intermediate high-dose autologous transplants without prior therapy induced 25% near complete response (
Blood 2004;104:3052–7
). No treatment related mortality was reported.

Non-myeloablative reduced intensity conditioning transplants after high-dose autologous transplants converted 18% complete remission to 70% complete remission and induced long-term disease free survival (

Blood 2002;100:755
); this therapy was though associated with 11% risk on treatment related mortality, mainly attributable to graft versus host diseases. Disease free survival was high at give follow-up. GVHD is well manageable with available agents.

In over 75% the disease was lethal prior to the non-myeloablative transplant era.

Conclusion: Conventional therapy in myeloma has been characterized by few low-dose regimens; myeloma have for years been undertreated. To improve disease outcome a systematic treatment approach from initial diagnosis for any of the stages I to III disease is required and herein discussed.

Topics:
dose-dense chemotherapy, multiple myeloma, transplantation, care plan, complete remission, cyclophosphamide, doxorubicin, prednisone, and vincristine, graft-versus-host disease, bortezomib, breast cancer, follow-up

Disclosure: No relevant conflicts of interest to declare.

2006, The American Society of Hematology
2006
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