48 NCCN Guidelines for Patients ® : Multiple Myeloma, 2018 4 Treatment guide Active (symptomatic) multiple myeloma If tests show a treatment response, then you have three options to choose from next. The first two options are only for patients who are able to have a stem cell transplant. This treatment destroys cells in the bone marrow with chemotherapy and then replaces them with healthy blood stem cells. An autologous stem cell transplant uses your own stem cells. An allogeneic stem cell transplant uses blood stem cells from another person, called a donor. For an autologous stem cell transplant, your stem cells will be harvested after primary treatment when the number of myeloma cells is low. Enough stem cells should be collected for two transplants depending on your age. This is needed since you may have a tandem stem cell transplant or a second transplant as later treatment. (See page 29 for more details about stem cell transplants.) After the allogeneic or autologous stem cell transplant, the follow-up tests listed in Guide 5 will be repeated to check for a treatment response. Tests to check the level of M-proteins in your blood and urine should be done at least every 3 months. If you aren’t able to have a stem cell transplant, or you don’t want a transplant right away, then there is a third option to choose from. The third option, for all patients, is to stay on primary treatment until no further treatment response is seen with follow-up tests. Your doctor will monitor the cancer with the follow-up tests listed in Guide 5 on page 43. Along with follow-up tests you will also be offered maintenance therapy after the autologous stem cell transplant. Maintenance therapy is medicine given in a lower dose or less often to keep (maintain) the good results of prior treatments. It is helpful to discuss the benefits and risks of taking maintenance therapy with your doctor. Recommended maintenance therapy options for myeloma following autologous stem cell transplant are listed next. Maintenance therapy Preferred options Other options • Lenalidomide • Bortezomib If tests do not show a treatment response, then you will receive treatment for myeloma that came back (relapsed) or continued to grow (progressed) during prior treatment. See the list of treatment options listed on the next page. These options are for people who have already received a drug treatment for myeloma. A number of drugs in the list have shown that long responses can occur in the advanced disease setting. For myeloma that has relapsed or is progressing (previously treated), the primary treatment options are also split into 3 groups—preferred regimens, other regimens, and those that are useful for some patients. Compared to “other” regimens, “preferred” regimens have thus far been proven to work better, have less severe side effects, or both. Some of the regimens listed in the “Other options” category have not yet gone through all phases of clinical trial testing.