Sequential or combination therapy for multiple myeloma

In myeloma management, whether to offer sequential or combination therapies has largely remained elusive, partly for the reason that there are no conclusive studies evaluating this question and partly owing to the paradigm shift in myeloma outcomes over the last decade raising the same question again, but now in a different context with active agents such as immunomodulatory drugs and proteasome inhibitors being available. Historically, in myeloma, combination cytotoxic chemotherapy compared with the standard-of-care melphalan and prednisone regimen resulted in similar response rates, raising the question of efficacy of the cytotoxic combination therapies with high toxicities and the preference for sequential therapies in order to lower the toxicity of the chosen treatment. However, with the use of more active novel agents with favorable toxicity profiles such as bortezomib, thalidomide and lenalidomide, re-evaluation of this question is necessary.