New approaches to treatment for multiple myeloma: durable remission and quality of life as primary goals.

New treatment approaches are changing the traditional paradigm for myeloma management. Partial or complete response with first-line therapy is now highly attainable. The focus of attention has thus shifted to obtaining the most durable remissions with the highest quality of life. A critical open question is whether more arduous and toxic therapies are justified with the intent to seek a cure. Patients with minimal symptoms at diagnosis are particularly reluctant to pursue aggressive strategies without documented long-term benefit. Conversely, patients with poor-risk molecular features, such as 13q deletion or t(4;14) translocation, can hopefully benefit from novel targeted therapies. New combinations incorporating bortezomib, thalidomide, and/or lenalidomide plus other novel agents offer the opportunity to explore therapy that is more effective and less toxic than in the past. The efficacy of single and tandem transplantation, which have documented long-term survival benefit, need to be compared with regimens integrating novel therapies. Whether true complete remission is a prerequisite for substantially improved survival is a central question in the framework of planned trials. The ultimate goal is to achieve clinical response (complete or partial) that offers the best quality remission for the longest period. Ideally, more effective induction and/or consolidation treatments will avoid concomitant toxicities and the need for maintenance therapies. Fortunately, new agents already offer longer-term disease control. The ongoing search for a cure will undoubtedly demand courage and dedication on the part of investigators and patients.