My initial reaction to the question of whether there are too many therapy choices for multiple myeloma is, “What a nice problem!”

It looks like the newest myeloma therapy, carfilzomib ^[1], will be widely available to relapsed/refractory patients soon.   Pomalidomide ^[2] shouldn’t be far behind, along with a half dozen new drugs that enhance the effectiveness of Revlimid ^[3] (lenalidomide) and Velcade ^[4] (bortezomib).

Soon, multiple myeloma patients may be treated with four-, five-, and even six-drug combinations.

This is a “nice problem,” except for several discouraging things.  At least in the near term, even oncologists/hematologists that specialize in treating multiple myeloma will only be guessing when deciding which drugs to use, when, and at what dose.

Timing is everything.  And it will most likely take five or more years to begin to sort all of this out, narrowing down the most effective choices for a particular patient at any given time.

Still, I stand by my initial reaction.  Choice is good.  But with choice comes responsibility:

• Responsibility for the patient and caregiver to learn as much as they can about multiple myeloma therapy options.
• Responsibility to understand when to start or switch to another therapy option.
• Responsibility to understand individualized dosing and what works best for you or your loved one.

In the world of quickly changing myeloma therapy options, all but the best and brightest myeloma experts will find themselves years behind when they sit down to discuss which therapy to try now.

The standard of care for multiple myeloma patients is already years behind.  Let me share a couple of examples with you.

Clinicians and myeloma docs are starting to realize that “less is more” when it comes to a number of different anti-myeloma drugs, especially Velcade and dexamethasone ^[5] (Decadron).

By reducing the dose and/or frequency with which these two important therapy agents are administered, researchers are learning that serious side effects can be significantly reduced, often with very little change in efficacy.

In other words, many multiple myeloma patients have been taking too much chemotherapy for years!

To be fair, it takes time to figure all of this out.  Phase 1 studies are designed to determine the maximum dosing a patient can withstand, not the optimum dose.

If we want new drugs to hit the market quickly, dosing miscalculations are to be expected.  After all, doctors would rather administer too much of a cancer chemotherapy than too little.  It's better for the patient to endure a few extra side effects than to let their cancer spread.

Next week I will share some specific examples of how patients understanding their therapy options can help minimize side effects, while optimizing results.

Until then, feel good and keep smiling!  Pat