**4. Consequences of MM being a disease of the elderly**

Results of examinations of QoL may help us to provide professional and effective support to the patient and their family through a holistic approach. Multidisciplinary co-operation is essential.

Multiple myeloma is the second most common hematological cancer and represents 10% of all hematological malignancies and 1 % of all cancers. The annual incidence of the disease in the US is 4 in 100,000. Approximately 100,000 new cases of MM are diagnosed each year worldwide [1]. MM accounts for 1% of all cancer-related deaths (approximately 72,000 deaths annually). The vast majority of the patients diagnosed with MM are 70-80 years old. MM is characterized by unregulated plasma cell proliferation in the bone marrow. These malignant plasma cells produce and secrete abnormal immunoglobulin (Ig) or immunoglobulin frag‐ ments. The monoclonal lg in the sera can cause hyperviscosity and this is one of the major symptoms of the disease. Clinical features and typical laboratory findings of MM include fatigue, bone pain, osteolythic bone lesions, pathologic bone fracture, anemia, hypercalcaemia, renal insufficiency, elevation of monoclonal Ig in the sera and/or in the urine and elevated erythrocyte sedimentation rate. The etiology of MM is unknown but aside from several environmental factors that are suspected, more and more cytogenetic alterations involved with

Despite the huge advance in the field of MM treatment, the disease has still remained incurable.

The main goal of treatment is the prolongation of survival. By the 1980's to 1990's, the survival of untreated patients had increased from mere months to 3-5 years. The introduction of intensive treatment, such as high-dose chemotherapy with autologous stem cell transplanta‐ tion (ASCT), further prolonged the overall survival. Novel agents, including immunomodu‐ latory drugs, such as thalidomide and lenalidomide, and the proteosome inhibitor bortezomib have dramatically changed the results in the past decade. Besides overall survival, disease-free survival has also been prolonged and the life expectancies of refractory and relapsed patients

The only curative treatment option is allogeneic stem cell transplantation due to antitumor immunity mediated by donor lymphocytes. However, morbidity and mortality related to graft-versus-host disease remain a challenge and regarding the average age of MM patients it

Depending on stage of the disease, median survival varies between 5-10 years for patients with ISS stage I disease undergoing stem-cell transplant and/or receiving novel anti-myeloma regimens [5]. However, outcomes have typically been poor for patients with high-risk disease and despite recent therapeutic advances the outlook for such patients remains unfavorable [6].

**2. Main features of Multiple Myeloma**

276 Multiple Myeloma - A Quick Reflection on the Fast Progress

the oncogenic process are detected [2,3].

**3. The aims of MM treatment**

are also largely improved [4].

remains an option for only a minority of patients.

The incidence of multiple myeloma (MM) increases with age and with the aging of the population, the number of adults with MM is expected to double in the next 20 years. Inten‐ sification of anti-myeloma therapy has resulted in a huge prolongation of survival data but this data mainly refers to younger patients who are eligible for these treatment modalities.

Older patients are ineligible for high-dose therapy because it causes an unacceptably high mortality rate in that patient population. Several co-morbidities of this setting or poor performance status prevent the success of intensive treatment.

On the other hand the significance of supportive measures for these patients has become a greater value. Besides the extended duration of survival, to improve the quality of survival by alleviating symptoms and achieving disease control while minimizing the adverse effects of the treatment has become a major goal [7].

Factors affecting prognosis include burden of disease, type of cytogenetic abnormality present, patient related factors (such as age and performance status) and treatment response factors.

Asymptomatic myeloma (smoldering myeloma) does not require any treatment, only obser‐ vation (watch and wait) is needed.

The choice of first-line treatment depends on a combination of factors.

For patients under 70 and with good performance status, the treatment of choice is high-dose chemotherapy with ASCT.

The majority of patients are transplantation-ineligible because of poor performance status or co-morbidities. These patients are therefore offered a less intensive single-agent or combina‐ tion chemotherapy. Typically, combination therapies include chemotherapy with an alkylat‐ ing agent and corticosteroids. More recent treatment options may also include combination therapies that incorporate drugs such as thalidomide, bortezomib and lenalidomide [8].

Regardingthemaintenancetherapy,ifcompleteremission(CR)hasbeenreachedthereisnoneed for maintenance therapy with thalidomide or lenalidomide because there is no significant differenceinOS.Inthecaseoflenalidomide,asignificantlyincreasedriskofsecondarymalignan‐ cieswasreported[9].MaintenanceisadvisedforpatientswhohavenotreachedCR.Inthesecases, one of the new drugs (thalidomide, lenalidomide or bortezomib) is the drug of choice [10].

However, in line with all these improvements in the field of chemotherapy, some new questions have emerged. The patient has gained a longer life, but is this life good enough? Is it worth the sea of difficulties during the treatment period and even afterward? To answer these questions, QoL measurements can offer valuable meaning.
