A recent paper compared the old and new therapies of multiple myeloma in elderly patients. Until 2007, chemotherapy with melphalan and prednisone (MP) was considered the standard treatment. However, new treatments are needed since the median survival rate with the MP regimen is only three years.

One method considered for the elderly is melphalan therapy followed by autologous stem cell transplantation (ASCT). An Italian multiple myeloma study group showed that a 100-milligram dose of melphalan followed by ASCT given twice worked better than MP in terms of response rate, event-free survival, and overall survival. The better survival rate was observed in patients aged 50-70 years and a subgroup of patients aged 65-70 years.

Another option is the combination of MP therapy with thalidomide (MPT). Overall survival was significantly longer in patients on MPT therapy when compared with MP therapy. MPT therapy has been tested in pilot studies with varying doses of thalidomide. The lower doses might be more appropriate for older patients since higher doses are associated with more adverse effects. Some of the risks associated with MPT treatment are thromboembolism and peripheral neuropathy. These risks are manageable with Lovenox (enoxaparin) and low-dose aspirin.

The combination of MP with Velcade (bortezomib) also showed promise. This therapy had a more rapid response time, greater overall survival, and longer time in between treatments than MP treatment alone. Side effects were hematologic, gastrointestinal, and neuropathic. They tended to occur mostly during the early cycles of treatment and in patients 75 years and older.

MP therapy has also been tested in combination with Revlimid (lenalidomide). A Phase 3 dose escalating trial found that such a regimen could be a promising treatment. The study examined 54 patients with a median age of 71 years.

Unlike the therapies mentioned, the combination of high-dose dexamethasone with alkylating agents is not recommended for the elderly because of its toxicity.

Dexamethasone therapy was combined with Revlimid (lenalidomide) in varying doses. The high-dose combination was significantly more toxic than the low-dose combination, which was found to be highly active in elderly patients newly diagnosed with multiple myeloma and more tolerable and manageable as compared to the high dose.

Trials have shown that treatments for elderly patients with multiple myeloma have improved from the standard MP therapy. Further studies still need to be done to determine the best possible therapy.

The entire article can be found in the November 2008 issue of Blood Reviews.