This document discusses the management of multiple myeloma in Asia, taking into account the resource limitations faced by developing countries in the region. ​ The introduction of novel drugs has significantly improved survival outcomes for multiple myeloma patients, but the guidelines based on evidence do not consider the resource disparities in Asian countries. ​ The document presents resource-stratified guidelines that correspond to different levels of healthcare resources and expertise, aiming to unify diagnostic and therapeutic guidelines and assist in the design of future studies in Asia. ​ The guidelines cover various aspects of multiple myeloma management, including diagnostic work-up, risk stratification, and treatment options for transplant eligible and ineligible patients. ​ The document also highlights the importance of genetic abnormalities and gene expression profiling in risk stratification.

Important Points:

1. Multiple myeloma is the second most frequent hematological malignancy globally, accounting for about 1% of all new cancer incidences and mortality. ​
2. The incidence of multiple myeloma is lower in Asian countries compared to western countries, but evidence suggests that it is increasing rapidly in Asia. ​
3. The guidelines for diagnostics and therapeutics of multiple myeloma in Asia have been largely adopted from western guidelines, but there are differences in treatment-emergent drug toxicities and pharmacogenomics in Asian patients. ​
4. Resource limitations and restricted access to novel drugs in many Asian countries hinder the delivery of optimum care to multiple myeloma patients. ​
5. The resource-stratified guidelines aim to provide recommendations for different levels of healthcare resources and infrastructure in Asian countries. ​
6. The diagnostic work-up for multiple myeloma includes tests to differentiate between symptomatic and asymptomatic disease, as well as tests for confirmation of the disease. ​
7. Risk stratification is crucial for prognostication, treatment decision-making, and comparing outcomes of therapeutic trials. ​ The International Staging System (ISS) based on serum albumin and β-2-microglobulin concentrations is a simple and robust staging system widely used for risk stratification. ​
8. Cytogenetic testing, particularly metaphase karyotyping and interphase fluorescent in-situ hybridization (FISH), can provide additional prognostic information. ​ Specific genetic abnormalities, such as t(4;14) and 17p13 deletion, are associated with poor survival outcomes. ​
9. Gene expression profiling has shown promise as an independent prognostic factor, but its clinical usefulness is still being assessed in clinical trials. ​
10. Treatment recommendations for transplant eligible and ineligible patients vary based on resource availability and risk stratification. ​
11. Bortezomib-based treatment has consistently shown improved outcomes for patients with t(4;14), but further confirmation is needed for patients with 17p13 deletion. ​
12. The document emphasizes the need for future prospective Asian studies to generate more evidence for formulating guidelines specific to the region. ​
13. Disease monitoring in multiple myeloma is done according to the International Myeloma Working Group uniform response criteria. ​
14. Front-line treatment options for patients eligible for transplantation depend on age, physical fitness, and resource availability. ​
15. Patients ineligible for transplantation, usually older than 65 years, are treated with a three-drug regimen that includes melphalan, prednisone, and either thalidomide or bortezomib. ​
16. Management of relapse and refractory multiple myeloma depends on various factors, including previous treatments, remission duration, eligibility for transplantation, and availability of novel drugs. ​
17. Supportive care plays a crucial role in minimizing therapy-related side effects and improving quality of life for patients with multiple myeloma. ​

Authors:

Tan D, Chng WJ, Chou T, Nawarawong W, Hwang SY, Chim CS, Chen W, Durie BG, Lee JH

Citation:

Lancet Oncol 2013; 14: e571–81
https://doi.org/10.1016/S1470-2045(13)70404-2 (https://doi.org/10.1016/S1470-2045(13)70404-2)