**Author details**

therapeutic strategies such as consolidation and maintenance treatments as well as total or continuous therapy [1–5, 24–29]. Currently, the following novel therapies are available for patients with MM: (1) immunomodulatory agents such as thalidomide, lenalidomide, and pomalidomide; (2) proteasome inhibitors such as bortezomib, carfilzomib, and ixazomib; (3) monoclonal antibodies such as daratumumab and elotuzumab; and (4) histone deacetylase inhibitors such as panobinostat and vorinostat [1–5, 26–29]. Other novel therapeutic options that are available for patients with RR-MM include chimeric antigen receptor T cells as well as other cellular and immunotherapies such as the use of specific antigen-presenting cells to overcome immune

Several studies and meta-analyses have shown that the most beneficial induction therapies in terms of overall response rate, overall survival (OS), and progression-free survival (PFS) in transplant-eligible patients with newly diagnosed MM are (1) bortezomib, lenalidomide, and dexamethasone (VRD), (2) bortezomib, cyclophosphamide, and dexamethasone, and (3) bortezomib, thalidomide, and dexamethasone [1, 33–35]. However, the standard induction therapy in patients with newly diagnosed MM is the VRD triplet regimen [4, 8]. Also, autologous HSCT is the standard of care for transplant eligible patients either upfront or at relapse [4, 8, 27]. Therefore, HD chemotherapy followed by autologous HSCT, which is an integral part in the treatment of the disease, is considered the standard of care for patients with MM who are eligible for HSCT [36–39]. With the recent advances in supportive care, autologous HSCT has been extended to include older patients with MM and those with comorbid medical conditions such as renal failure (RF) [37, 38]. Nevertheless, autologous HSCT and novel therapies are complementary to each other in the management of patients with MM [37, 40]. Studies have shown that post-HSCT consolidation and maintenance treatments can further improve the outcome of patients with MM [8, 27, 41]. In particular, the use of either proteasome inhibitors such as bortezomib or immunomodulatory drugs such as lenalidomide in the maintenance therapy is associated with increased OS and PFS [42–46]. However, for transplant-eligible patients, stratified maintenance therapy based on risk features and depth of response is recommended [47]. Monitoring disease response at various stages of treatment is essential, and studies have shown that monitoring of minimal residual disease (MRD) is associated with longer PFS and OS [48, 49]. Patients with high-risk (HR) cytogenetics require not only specific induction therapies but also autologous HSCT as well as consolidation and maintenance therapies [50, 51]. For such patients, deeper responses should be obtained as several studies and meta-analyses have shown that MRD negativity is a strong predictor of clinical outcome and is associated with

The numerous treatment modalities that are available for patients with MM have shown their efficacy, but they have their own adverse effects that include BM suppression and infectious

Also, there is very limited access to effective care in many countries particularly in sub-Saharan Africa. Additionally, the available novel therapies are rather expensive, and the economic bur-

Progression of MM is related to the underlying BM microenvironment and to the genetic heterogeneity of the disease [7, 19]. Studies have shown that the main causes of death in patients with MM are infections, comorbid medical conditions such as RF, having RR disease, and the presence

incompetence and engineered T cells as well as natural killer cell products [30–32].

long-term survival [49, 52, 53].

4 Update on Multiple Myeloma

complications that may be life-threatening [9, 10, 54].

den of the disease is huge [13, 14, 55–57].

Khalid Ahmed Al-Anazi

Address all correspondence to: kaa\_alanazi@yahoo.com

Department of Hematology and Hematopoietic Stem Cell Transplantation, Oncology Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia
