Treatment of Newly Diagnosed Myeloma in Patients not Eligible for Transplantation

Melphalan plus prednisone (MP) has long been considered the gold-standard treatment for elderly patients with newly diagnosed myeloma, and it still forms the backbone for combinations based on novel agents. MP plus thalidomide (MPT), bortezomib (VMP), or lenalidomide (MPR), as induction plus maintenance, have proved to be superior to MP and are currently the treatment of choice for this population. Low-dose dexamethasone in combination with thalidomide and cyclophosphamide (CTDa) or with lenalidomide can be an alternative option for these patients. The benefit of these novel agents in terms of prolonged survival is accompanied by increases in treatment-related adverse events, however, which may be particularly pronounced in older individuals. In managing these patients, efficacy and toxicity should be balanced, and thus prophylactic measures to avoid adverse effects are mandatory. Moreover, reduced-intensity regimens are recommended for fragile or very elderly patients. Finally, the wide array of new treatment options will facilitate individualized treatment approaches, based on characteristics of the disease, patient comorbidities, and personal and social circumstances.