We asked about up-front treatment for an older, transplant-ineligible patient, in this case aged 77, at standard risk. The 2 most common choices were Rd (also used by both faculty) and RVD, often used at reduced doses as in the “RVD lite” regimen. One surprising finding is that the use of melphalan continues in a small subset of oncologists, a practice likely to change considering the data from the FIRST trial that demonstrated a significant PFS and OS benefit with continuous Rd compared to melphalan/prednisone/thalidomide. Dr Munshi evaluates patients’ frailty and comorbidities in choosing between RVD lite and Rd but leans toward RVD for symptomatic patients to induce a more rapid response.

Benboubker L et al. Lenalidomide and dexamethasone in transplant-ineligible patients with myeloma. N Engl J Med 2014;371(10):906-17. Abstract

Reece D. Update on the initial therapy of multiple myeloma. Am Soc Clin Oncol Educ Book 2013. Abstract

Mateos MV et al. Initial treatment of transplant-ineligible patients in multiple myeloma. Expert Rev Hematol 2014;7(1):67-77. Abstract