Virtually all patients treated for MM will receive systemic therapy.

Induction therapy is the first phase of initial therapy. It aims to rapidly reduce the burden of MM. Induction therapy can include a combination of:

• immunomodulatory drugs (IMiDs)
• proteasome inhibitors (PIs)
• chemotherapy
• monoclonal antibodies (mAbs)

Induction regimens will differ depending on whether the patient is eligible for a transplant and/ or fit for high-dose chemotherapy. Typically, transplant-eligible patients will undergo a three-drug

combination induction therapy that contains an IMiD and a PI with corticosteroids. Patients who are not transplant eligible may undergo the same triple combination with dose attenuation, or a double combination containing an IMiD or a PI with corticosteroids. Factors such as potential toxicity and patient fitness should be considered when choosing a combination.

Autologous stem cell transplant

ASCT uses the patient’s own stem cells to facilitate a faster bone marrow recovery after high-dose chemotherapy. When incorporated into initial treatment, ASCT improves both progression-free survival and overall survival compared with a non-ASCT approach for transplant-eligible patients.

It is recommended for patients up to age 70 who have good performance status and organ reserve.

Tandem ASCT

Patients with high-risk cytogenetics may benefit from a second ASCT within six months of the first. This option has higher acute toxicity.

Allogeneic stem cell transplant

AlloSCT uses stem cells from a donor rather than the patient’s own stem cells. Due to the lack of consistent survival benefit, alloSCT is not standard of care. However, for patients with high-risk MM who have a poor long-term prognosis, it may be considered in their initial course of therapy or first relapse after chemotherapy, when the risk of disease progression may outweigh the transplant- related risks. It is recommended that alloSCT be performed in a clinical trial setting.

Consolidation therapy

This is a short course of drug therapy of similar intensity to induction therapy that is given after ASCT to further reduce the burden of myeloma. Consolidation therapy is not routine but may benefit some patients who have not had effective induction therapy and who have not achieved complete remission post ASCT.

Maintenance therapy

This is continuous drug treatment to keep the MM in remission and is usually given for at least two years or until disease progression.

For more information see the MSAG Clinical practice guideline: multiple myeloma (Quach & Prince 2019).

Timeframes for starting treatment

Treatment should begin within two weeks of establishing the diagnosis and staging. However, in cases with critical organ compromise, such as renal failure and cord compression, or rapid clinical progression, it may be vital to start treatment within 24 hours of diagnosis.

Training and experience required of the appropriate specialists

Haematologists or medical oncologists must have training and experience of this standard:

• Fellow of the Royal Australian College of Physicians (or equivalent)
• adequate training and experience that enables institutional credentialing and agreed scope of practice within this area (ACSQHC 2015).

Cancer nurses should have accredited training in these areas:

• anti-cancer treatment administration
• specialised nursing care for patients undergoing cancer treatments, including side effects and symptom management
• the handling and disposal of cytotoxic waste (ACSQHC 2020).

Myeloma specialist nurses are recommended where possible, as specialist cancer nurses have been shown to improve symptom control, treatment adherence, self-efficacy and patient-reported outcomes, as well as reducing unplanned hospital admissions (Charalambous et al. 2018).

Systemic therapy should be prepared by a pharmacist whose background includes this experience:

• adequate training in systemic therapy medication, including dosing calculations according to protocols, formulations and/or preparation.

In cases where no haematologist is locally available (e.g. regional or remote areas), some components of less complex therapies, such as bisphosphonate therapy or other supportive therapies, may be delivered by a general practitioner or nurse with training and experience that enables credentialing and agreed scope of practice within this area. This should be in accordance with a detailed treatment plan or agreed protocol, and with communication as agreed with the medical oncologist or as clinically required.

The training and experience of the appropriate specialist should be documented.

Health service characteristics

To provide safe and quality care for patients having systemic therapy, health services should have these features:

• a clearly defined path to emergency care and advice after hours
• access to diagnostic pathology including basic haematology and biochemistry, and imaging
• cytotoxic drugs prepared in a pharmacy with appropriate facilities
• occupational health and safety guidelines regarding handling of cytotoxic drugs, including preparation, waste procedures and spill kits (eviQ 2019)
• guidelines and protocols to deliver treatment safely (including dealing with extravasation of drugs)
• coordination for combined therapy with radiation therapy, especially where facilities are not co-located
• appropriate molecular pathology

Hospital or treatment unit characteristics for providing safe and quality care for ASCT include:

• access to National Association of Testing Authorities (NATA)-accredited apheresis for collecting peripheral blood progenitor cells, with appropriately credentialed nursing staff available to operate cell separators
• access to a NATA-accredited therapeutic cellular laboratory for the appropriate cryopreservation and handling of peripheral blood progenitor cells
• dedicated credentialed transplant haematologists and a multidisciplinary team credentialed in caring for high-acuity patients
• access to an onsite intensive care unit with credentialed intensivists
• dedicated standard isolation rooms (single rooms with ensuite and clinical hand-washing facilities).