**6. Drugs available for intensive treatments**

It is necessary to note that novel agents, imunomodulatory drugs (thalidomide, lenalidomide, pomalidomide) and proteasome inhibitors (bortezomib, carfilzomib), are key players currently used in therapeutical protocols and/or in the clinical trials. The 'old' drugs, such as alkylating cytostatics and glucocorticoids, still belong to the most effective group of drugs in multiple myeloma. These old drugs are used in most treatment protocols. The therapeutic strategy in newly diagnosed patients is described in details in another chapter (Induction Therapy in Multiple Myeloma). The same drugs could be used in a relapse setting depending on the components of initial therapy, efficacy and toxicity of the initial therapy, patient status and circumstances of relapse (age, performance status, glucose metabolism, aggressive vs nonaggressive relapse, bone marrow reserve, renal function impairment, pre-existing peripheral neuropathy and quality of life considerations).

when RMP-R treatment is used with maintenance therapy compared to RMP without main‐ tenance therapy in a study of seniors MM-015 in [31]. RMP-R treatment ensured one of the longest median of PFS (31 months). Maintenance therapy of lenalidomide was generally well tolerated with no signs of cumulative toxicity as in the case of thalidomide. Although the occurrence of secondary malignancies after lenalidomide treatment was increased, the risk of disease progression or death by MM overcame this risk in [5]. Despite superb results of maintenance therapy by lenalidomide, it is not yet approved for maintenance therapy till the end of the year 2012 mainly due to safety reasons, although long-term results are also limited.

Strategies for the Treatment of Multiple Myeloma in 2013: Moving Toward the Cure

http://dx.doi.org/10.5772/55366

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In the study GEM/Pethema, patients were induced by VMP (bortezomib, melphalan, predni‐ solon) or VTP (bortezomib, thalidomid, prednisolon) and randomized for maintenance treatment (VT or VP) for 3 years. Maintenance treatment with bortezomib increased IF-CR from 24% to 42% in [32]. Maintenance treatment with bortezomib was better after autologous transplantation in comparison to thalidomide (PFS 28 vs. 35 months; p=0.002), and overall survival benefit was seen not only for the whole group (p = 0.049) but also for high risk patients in [33]. So far, there is not enough information about maintenance therapy with bortezomib although the data are promising. The change in the route of bortezomib administration from intravenous to subcutaneous significantly reduced toxicity, mainly peripheral polyneurop‐ athy in [34]. Thus, long-term use of bortezomib will be more suitable for patients starting at the end of the year 2012. Moreover, novel proteasome inhibitors that undergo clinical trials have limited toxicity and per oral route of administration that further increased their potential

Multiple myeloma is curable if an intensive combination regime is used upfront. Long-term complete remission becomes a more important factor than reaching complete remission. Complete remission that lasts more than three years is the first milestone on the road towards curability in [36]. It is necessary to accentuate that in the light of current knowledge and longterm experience with intensive regimens, the possibility of curing MM patients is being discussed from the end of 2011 in [37]. The first report, at the time very provocative, was presented at ASH in 2009 suggesting the possibility of a cure in 2009 in [29]. This was a major

Which MM patients have a chance of a cure and what is that chance? Curability depends on reaching a deep and constant complete remission which is most probable and possible in MM patients with a favorable prognosis suitable for autologous transplantation. Of which are treated by an intensive combination treatment composed of the most effectively available drugs. These drugs are set into a complex block of entry induction therapy followed by

**9. Inhibitors of proteasomes**

for maintenance therapy in [35].

**10. Curability of available treatment options**

breakthrough in the observation of this malignant disease.
