The Role of High-Dose Chemotherapy and Stem-Cell Transplantation in Patients with Multiple Myeloma: A Practice Guideline of the Cancer Care Ontario Practice Guidelines Initiative Bortezomib in multiple myeloma and lymphoma: a systematic review and clinical practice guideline Effects of exercise in combination with epoetin alfa during high-dose chemotherapy and autologous peripheral blood stem cell transplantation for multiple myeloma. High-dose chemotherapy with hematopoietic stem-cell rescue for multiple myeloma. Efficient mobilization of peripheral blood stem cells following CAD chemotherapy and a single dose of pegylated G-CSF in patients with multiple myeloma Addition of lenalidomide to melphalan in the treatment of newly diagnosed multiple myeloma: the National Cancer Institute of Canada Clinical Trials Group MY.11 trial Facilitating exercise adherence for patients with multiple myeloma. Autologous haemopoietic stem-cell transplantation followed by allogeneic or autologous haemopoietic stem-cell transplantation in patients with multiple myeloma (BMT CTN 0102): a phase 3 biological assignment trial.
After more than three decades of clinical trials testing various st and ard-dose chemotherapy regimens , the disease course of patients with multiple myeloma has not changed appreciably . Conventional chemotherapy can provide effective palliation but is not curative ( 1 ) . Case series have described encouraging results in patients with myeloma undergoing allogeneic or autologous bone marrow or peripheral blood stem-cell transplantation ( 2 ) . Other studies of transplantation , including r and omized trials , have been reported in the past 6 years ( 3 , 4 ) . To facilitate decisions about treatment options , practice guidelines have been developed for use by health care providers and consumers . In Ontario , Canada , cancer treatments and policies are led by a state-funded organization , Cancer Care Ontario . To help derive treatment options , Cancer Care Ontario has developed the Program in Evidence -Based Care , which includes the Practice Guidelines Initiative . Disease Site Groups ( DSGs ) , which comprise physicians , epidemiologists , and consumers , develop guidelines through a systematic process that involves assessment of evidence , consensus , and a validation process involving practitioners from across the province . Guideline topics are chosen through a prioritization process that includes the burden of illness , availability of evidence , perceived variation in practice , the potential to affect treatment decisions , and re source utilization . The Hematology DSG noted that the use of transplantation for patients with myeloma varied among practice s across the province . Variability in practice and emerging evidence of higher quality made this a priority topic for guideline development . To approach this topic , the DSG addressed the following questions : What is optimal st and ard-dose chemotherapy for patients with myeloma ? In terms of survival , is  peripheral blood stem-cell  or  marrow transplantation better than conventional chemotherapy ? What is the relative efficacy of autologous versus allogeneic transplantation ? What specifics of the transplantation process can be recommended ? When should transplantation be performed ? Who should ( or should not ) receive a transplant ? Methods Overview of Guideline Development This guideline was developed by the Cancer Care Ontario Practice Guidelines Initiative ( CCOPGI ) using the methods of the Practice Guidelines Development Cycle ( 5 ) . Members of the CCOPGI 's Hematology DSG selected , review ed , and interpreted the evidence . This DSG comprises 25 members , including hematologists , medical and radiation oncologists , an epidemiologist , and 2 lay representatives . Several of the physician members have background training in epidemiology ; 8 hematologists regularly perform stem-cell transplantation in clinical practice . The DSG 's draft recommendations were circulated through a mailed survey to hematologists and medical or radiation oncologists in Ontario for feedback and involvement in a consensus process . Responses were used to guide the reformatting of the draft into the final guideline recommendations . The Practice Guidelines Co-ordinating Committee ( PGCC ) , which ensures consistency of guideline development across the DSGs of various tumor sites , approved the guideline . The CCOPGI has a st and ardized process to up date each guideline report ; the current guideline was up date d and review ed by the PGCC in October 2000 . Literature Search Strategy We search ed the MEDLINE , CANCERLIT , and Cochrane Library data bases for literature published from 1992 to December 1997 and subsequently up date d the search in October 1998 , June 1999 , and April 2000 . For the search es , we combined multiple myeloma ( as a Medical Subject Heading [ MeSH ] and text word ) with bone marrow transplantation ( MeSH and text word ) and drug therapy ( MeSH ) . Then , we combined these terms with the search terms for the following study design s : practice guidelines ; systematic review s or meta-analyses ; review s ; r and omized , controlled trials ; controlled clinical trials ; and comparative studies . In addition , we search ed the PubMed and Physician Data Query ( PDQ ) ( www.cancer.gov/ search / clinical _ trials/ ) data bases and review ed relevant conference proceedings ( American Society of Hematology , 1997 to 1999 , and American Society of Clinical Oncology , 1999 to 2000 ) , article bibliographies , and personal files . To address the issue of optimal chemotherapy , we performed an additional search of the same data bases using the term multiple myeloma ( MeSH ) combined with r and omized , controlled trials ( MeSH ) and the text word r and om in the title . Inclusion Criteria We selected study reports meeting one of the three following criteria : r and omized trial or meta- analysis of therapy for patients with myeloma that reported survival or quality -of-life outcomes ; nonr and omized comparative trial that addressed transplantation strategy , including a contemporaneous control group , and that reported survival or quality -of-life outcomes ; or economic evaluation that addressed transplantation strategy . Because of insufficient data on the specifics of the transplantation process and the patients who would be most likely to benefit from transplantation , we performed a second search , which identified data from noncomparative case-series studies . Data Extraction and Interpretative Summary Three members of the DSG , including an epidemiologist , determined eligibility of the articles and abstract s obtained from the literature search . The lead DSG member for this guideline extracted and summarized relevant data according to the guideline question addressed . The DSG members then review ed the summarized data and key articles . The DSG met formally three to four times annually ; at these meetings , the members method ologically assessed the articles , interpreted the data , and debated specific points in an attempt to reach a consensus . Synthesizing the Evidence Because all of the nine r and omized trials on transplantation addressed different questions , we did not statistically pool the data . DSG Consensus Process Through an iterative process that included debate at formal meetings and circulation of draft recommendations , we considered the implication s of the appraised data for each guideline question . With this process , attempts were made to reach consensus ; when this was impossible , minority opinions were recorded . Approval by each member of the DSG was required before circulation of the draft version for practitioner feedback and su bmi ssion of the final guideline to the PGCC . Practitioner Feedback To obtain practitioner feedback , we mailed a survey to 211 practitioners in Ontario ( 94 hematologists , 93 medical oncologists , and 24 radiation oncologists ) . The survey consisted of st and ardized items asking the practitioner to rate the quality of each draft guideline and to judge whether the draft recommendations should serve as a practice guideline . Written comments were invited . Follow-up reminders were sent at 2 weeks ( by postcard ) and 4 weeks ( entire package ) . After exclusion of 18 retired practitioners , 137 of 193 practitioners ( 71 % ) responded ; 90 of 137 respondents ( 66 % ) indicated that the guideline was relevant to their practice . Approval of the draft guideline was strong among these 90 practitioners : 91 % agreed or strongly agreed that the summary of the evidence was acceptable , 87 % agreed with the draft recommendations , and 81 % approved of the recommendations as a practice guideline . Thirty-nine respondents provided written comments ; these comments were , like the other responses , incorporated in the final guideline . Results Sixty-six reports met the criteria for inclusion and are categorized in Table 1 . In each section below , we describe the studies , summarize results , and describe the guideline development . Table 1 . Evidence Included in This Practice Guideline Report What Is Optimal St and ard-Dose Chemotherapy  for Patients with Multiple Myeloma ? To properly compare transplantation with conventional chemotherapy , we must define optimal conventional chemotherapy . We identified 30 r and omized trials comparing therapies in previously untreated patients . Four meta-analyses ( 6 - 9 ) evaluated these data . The Myeloma Trialists ' Collaborative Group ( 7 ) compared combination chemotherapy with melphalan plus prednisone in a meta- analysis of 27 trials . Twenty of these trials supplied individual-patient data . No difference in survival was detected . The proportional reduction in the annual odds of death was 1.5 % in favor of combination chemotherapy ( 95 % CI , 8 % to 5 % ; P > 0.2 ) , with an odds ratio ( OR ) of 0.99 ( CI , 0.93 to 1.05 ) . An earlier literature -based meta- analysis ( 6 ) of 18 trials also failed to detect a survival difference between groups ( OR , 1.04 [ CI , 0.90 to 1.19 ] ; P > 0.2 ) . Two meta-analyses evaluated interferon for multiple myeloma . An overview of 24 r and omized trials published in abstract form ( 8) demonstrated that interferon improved recurrence-free survival by 6 months and improved 3-year overall survival by 4 % . Another meta- analysis ( 9 ) measured survival by a unique measure called the mean lifetime survival . This meta- analysis found no difference in survival rate between the group receiving interferon and the group not receiving interferon ( 3.9 vs. 3.4 years , respectively ; P = 0.095 ) . Guideline Recommendation Multiagent chemotherapy or melphalan plus prednisone is appropriate therapy for a control group in a comparison of transplantation versus st and ard-dose therapy . The addition of interferon is unlikely to influence outcomes in the control group . In Terms of Survival , Is Autologous Peripheral Blood Stem-Cell or Bone Marrow Transplantation Better than Conventional Chemotherapy ? We review ed two r and omized and three nonr and omized comparisons ( Table 2 ) . Attal and colleagues ( 3 ) r and omly assigned 200 previously untreated patients younger than 65 years of age with stage II or III ( 40 ) myeloma to conventional chemotherapy or to a strategy that included autologous bone marrow transplantation . Patients were r and omly Questions In patients with multiple myeloma , Waldenström macroglobulinemia , or lymphoma , what is the efficacy of bortezomib alone or in combination as measured by survival , quality of life , disease control ( for example , time to progression ) , response duration , or response rate ? What is the toxicity associated with the use of bortezomib ? Which patients are more or less likely to benefit from treatment with bortezomib ? Perspectives Evidence was selected and review ed by two members of the Hematology Disease Site Group and by method ologists from the Program in Evidence -based Care ( pebc ) at Cancer Care Ontario . The practice guideline report was review ed and approved by the Hematology Disease Site Group , which comprises hematologists , medical and radiation oncologists , and a patient representative . As part of an external review process , the report was disseminated to practitioners throughout Ontario to obtain their feedback . Outcomes Outcomes of interest were overall survival , quality of life , response rates and duration , and rates of adverse events . Methodology A systematic search was conducted of the medline , embase , HealthStar , cinahl , and Cochrane Library data bases for primary articles and practice guidelines . The result ing evidence informed the development of clinical practice recommendations . Those recommendations were appraised by a sample of practitioners in Ontario and modified in response to the feedback received . The systematic review and modified recommendations were approved by a review body w theithin pebc . Results The literature review found one r and omized controlled trial ( rct ) —the only published rct of bortezomib in relapsed myeloma . A number of phase ii studies were also retrieved , including a r and omized phase ii study . No r and omized trials were retrieved for lymphoma . The rct found bortezomib to be superior to high-dose dexamethasone for median time to progression and 1-year survival in patients with relapsed myeloma , although grade 3 adverse events were more common in the bortezomib arm . Bortezomib is recommended as the preferred treatment option in patients with myeloma relapsing within 1 year of the conclusion of initial treatment ; it may also be a reasonable option in patients relapsing at least 1 year after autologous stem-cell transplantation . Practice Guideline This evidence -based series applies to adult patients with myeloma , Waldenström macroglobulinemia , or lymphoma of any type , stage , histology , or performance status . Recommendations Based on the results of a large well-conducted rct , which represents the only published r and omized study in relapsed myeloma , the Hematology Disease Site Group ( dsg ) offers the following recommendations : For patients with myeloma refractory to or relapsing within 1 year of the conclusion of initial or subsequent treatment or treatments , including autologous stem-cell transplantation , and who are c and i date s for further chemotherapy , bortezomib is recommended as the preferred treatment option . Bortezomib is also a reasonable option for patients relapsing at least 1 year after autologous stem-cell transplantation . The dsg is aware that thalidomide , alkylating agents , or repeat transplantation may also be options for these patients . However , evaluation of these other options is beyond the scope of this practice guideline . For patients with myeloma relapsing at least 1 year after the conclusion of alkylating agent – based chemotherapy who are c and i date s for further chemotherapy , further treatment with alkylating agent – based chemotherapy is recommended . Evidence is insufficient to support the use of bortezomib in patients with non-Hodgkin lymphoma or Waldenström macroglobulinemia outside of clinical trials . Qualifying Statements Limited evidence supports the appropriateness of a specific time-to-relapse period as being indicative of treatment-insensitive disease . The 1-year threshold provided in the foregoing recommendations is based on the opinion of the Hematology dsg . For specific details related to the administration of bortezomib therapy , the dsg suggests that clinicians refer to the protocol s used in major trials . Some of those details are provided here for informational purpose s. Dosage Bortezomib 1.3,g/m2 is given as a rapid intravenous bolus over 3–5 seconds on days 1 , 4 , 8 , and 11 of a 21-day cycle ; a minimum of 72 hours between doses is required to allow for recovery of normal proteasome function . Vital signs should be checked before and after each dose . A complete blood count is recommended before each dose , with blood chemistries ( including electrolyte and creatinine levels ) monitored at a minimum on days 1 and 8 of each cycle . The dose of bortezomib should be reduced or held immediately upon development of painful neuropathy , as described in the product monograph ; dose modification may also be required for peripheral sensory neuropathy without pain or for other toxicities . Most toxicities are reversible if dose modification guidelines are followed . Response to Treatment Responses are usually apparent by 6 weeks ( 2 cycles ) . For patients achieving complete remission ( determined by negative electrophoresis and immunofixation ) , bortezomib should be given for 2 additional cycles beyond the date of confirmed complete remission . In patients with progressive disease after 2 cycles or stable disease after 4 cycles , dexamethasone added to the bortezomib regimen ( 20 mg by mouth the day of and the day after each bortezomib dose ) may produce an objective response .  Bortezomib ( with or without dexamethasone ) should be continued in patients showing benefit from therapy ( excluding those in complete remission ) unless disease progression or significant toxicity is observed . Therapy should be discontinued in patients who do not respond to bortezomib alone if disease progression is seen within 2 cycles of the addition of dexamethasone . The Hematology dsg recognizes that thalidomide is an active agent in multiple myeloma patients who have relapsed after autologous stem-cell transplantation or who are refractory to alkylating agent – based chemotherapy . To date , no reported rcts have evaluated thalidomide in this role , and specifically , no trials have compared thalidomide with bortezomib . Given these limitations , the members of the Hematology dsg regard thalidomide or bortezomib as therapy alternatives to dexamethasone PURPOSE / OBJECTIVES To determine the effect of aerobic and strength resistance training and epoetin alfa ( EPO ) therapy on transfusions , stem cell collection s , transplantation recovery , and multiple myeloma treatment response . DESIGN R and omized clinical trial . SETTING A myeloma research and therapy center in the south central United States . SAMPLE 135 patients with multiple myeloma , 120 evaluable . METHODS R and om assignment to exercise or usual care groups . All patients received EPO based on an algorithm . Aerobic capacity , using the six-minute walk test , was assessed prior to induction chemotherapy , prior to stem cell mobilization , and following stem cell collection for all patients and before and after transplantation for patients continuing in the study . Data analysis included analysis of variance to compare other outcome variables by groups . MAIN RESEARCH VARIABLES Number of red blood cell and platelet transfusions during transplantation , number of attempts at and total number of days of stem cell collection , time to recovery after transplantation , and response to intensive therapy for multiple myeloma . FINDINGS Recovery and treatment response were not significantly different between groups after transplantation . The exercise group had significantly fewer red blood cell transfusions and fewer attempts at stem cell collection . Serious adverse events were similar in each group . CONCLUSIONS Exercise with prophylactic EPO therapy reduces the number of RBC transfusions and attempts at stem cell collection for patients receiving intensive treatment for multiple myeloma . IMPLICATION S FOR NURSING Exercise is safe and has many physiologic benefits for patients receiving multiple myeloma treatment BACKGROUND High-dose therapy with supporting autologous stem-cell transplantation remains a controversial treatment for cancer . In multiple myeloma , first-line regimens incorporating high-dose therapy yield higher remission rates than do conventional-dose treatments , but evidence that this translates into improved survival is limited . METHODS In this multicenter study , the Medical Research Council Myeloma VII Trial , we r and omly assigned 407 patients with previously untreated multiple myeloma who were younger than 65 years of age to receive either st and ard conventional-dose combination chemotherapy or high-dose therapy and an autologous stem-cell transplant . RESULTS Among the 401 patients who could be evaluated , the rates of complete response were higher in the intensive-therapy group than in the st and ard-therapy group ( 44 percent vs. 8 percent , P<0.001 ) . The rates of partial response were similar ( 42 percent and 40 percent , respectively ; P=0.72 ) , and the rates of minimal response were lower in the intensive-therapy group than in the st and ard-therapy group ( 3 percent vs. 18 percent , P<0.001 ) . Intention-to-treat analysis showed a higher rate of overall survival ( P=0.04 by the log-rank test ) and progression-free survival ( P<0.001 ) in the intensive-therapy group than in the st and ard-therapy group . As compared with st and ard therapy , intensive treatment increased median survival by almost 1 year ( 54.1 months [ 95 percent confidence interval , 44.9 to 65.2 ] vs. 42.3 months [ 95 percent confidence interval , 33.1 to 51.6 ] ) . There was a trend toward a greater survival benefit in the group of patients with a poor prognosis , as defined by a high beta2-microglobulin level ( more than 8 mg per liter ) . CONCLUSIONS High-dose therapy with autologous stem-cell rescue is an effective first-line treatment for patients with multiple myeloma who are younger than 65 years of age High-dose chemotherapy followed by autologous blood stem cell transplantation is the st and ard treatment for myeloma patients . In this study , CAD ( cyclophosphamide , adriamycin , dexamethasone ) chemotherapy and a single dose of pegfilgrastim ( 12 mg ) was highly effective in mobilizing peripheral blood stem cells ( PBSCs ) for subsequent transplantation , with 88 % of patients ( n=26 ) achieving the CD34 + cell harvest target of ⩾7.50 × 106 CD34 + cells/kg body weight , following a median of two apheresis procedures ( range 1–4 ) and with first apheresis performed at a median day 13 after CAD application ( range 10–20 ) . Patients treated with pegfilgrastim showed a reduced time to first apheresis procedure from mobilization compared with filgrastim-mobilized historical matched controls ( n=52 , P=0.015 ) . The pegfilgrastim mobilization regimen allowed for transplantation of a median of 3.58 × 106 CD34 + cells/kg body weight while leaving sufficient stored cells for a second high-dose regimen and back-ups in most patients . Engraftment following transplantation was comparable to filgrastim , with a median time of 14 days to leucocyte ⩾1.0 × 109/l ( range 10–21 ) and 11 days to platelets ⩾20 × 109/l ( range 0–15 ) . The results of this study thus provide further support for the clinical utility of pegfilgrastim for the mobilization of PBSC following chemotherapy in cancer patients scheduled for transplantation Oral melphalan and prednisone remain an effective and tolerable treatment for patients with multiple myeloma . For approximately 40 years , this combination has been the st and ard of care for patients not proceeding to stem cell transplant . Within the last 10 years , new agents have been found to be efficacious in the relapsed/refractory setting . Within the last year , two trials of added thalidomide in the newly diagnosed setting have demonstrated outcomes superior to those achieved with melphalan and prednisone alone . This improved outcome comes at the cost of increased toxicity . The National Cancer Institute of Canada Clinical Trials Group ( ncic ctg ) has recently developed a r and omized phase ii trial ( MY.11 ) that uses a combination of lenalidomide with melphalan for patients with newly diagnosed multiple myeloma .  Lenalidomide is a thalidomide analogue and , like thalidomide , is thought to work through immunomodulatory effects . It was shown to have activity in patients with relapsed or refractory disease and , in combination with dexamethasone , is superior to dexamethasone alone . Lenalidomide holds promise as a more effective and potentially less toxic derivative of thalidomide . Experience with lenalidomide in combination with chemotherapy is very limited , and the purpose of MY.11 is to establish tolerability and to gain knowledge about efficacy . The information gained from MY.11 is expected to help inform dosing levels and schedules for a large phase iii trial being developed by the Eastern Cooperative Oncology Group that will include participation by the ncic ctg Physical exercise is becoming an accepted part of therapy for many patients with cancer .  Exercise may alleviate patients ' fatigue and improve physical performance and psychological outlook . Much of the research is limited to women with breast cancer and excludes patients with bone metastases . This article reports on the authors ' work in facilitating exercise adherence for patients with multiple myeloma ( MM ) and bone lesions while they were enrolled in a feasibility/pilot exercise study as they were receiving treatment for their disease in an outpatient treatment program . The exercise program for these patients receiving high-dose chemotherapy and stem cell transplantation consisted of aerobic and strength-building components . The program was home based , and patients performed exercises without direct supervision . On average , the patients completed the six-month exercise prescription 75 % of the time . Overall trends showed that all 14 patients in the exercise group  improved in several areas of testing , and the test results of all 10 patients in the usual-care group declined . Flexibility and simplicity are essential when design ing exercise programs for patients , and encouragement and support also are needed to help patients adhere to prescribed exercise BACKGROUND Autologous haemopoietic stem-cell transplantation ( HSCT ) improves survival in patients with multiple myeloma , but disease progression remains an issue . Allogeneic HSCT might reduce disease progression , but can be associated with high treatment-related mortality . Thus , we aim ed to assess effectiveness of allogeneic HSCT with non-myeloablative conditioning after autologous HSCT compared with t and em autologous HSCT . METHODS In our phase 3 biological assignment trial , we enrolled patients with multiple myeloma attending 37 transplant centres in the USA . Patients ( < 70 years old ) with adequate organ function who had completed at least three cycles of systemic antimyeloma therapy within the past 10 months were eligible for inclusion . We assigned patients to receive an autologous HSCT followed by an allogeneic HSCT ( auto-allo group ) or t and em autologous HSCTs ( auto-auto group ) on the basis of the availability of an HLA-matched sibling donor . Patients in the auto-auto group subsequently underwent a r and om allocation ( 1:1 ) to maintenance therapy ( thalidomide plus dexamethasone ) or observation . To avoid enrolment bias , we classified patients as st and ard risk or high risk on the basis of cytogenetics and β2-microglobulin concentrations . We used the Kaplan-Meier method to estimate differences in 3-year progression-free survival ( PFS ; primary endpoint ) between patients with st and ard-risk disease in the auto-allo group and the best results from the auto-auto group ( maintenance , observation , or pooled ) . This study is registered with Clinical Trials.gov , number NCT00075829 . FINDINGS Between Dec 17 , 2003 , and March 30 , 2007 , we enrolled 710 patients , of whom 625 had st and ard-risk disease and received an autologous HSCT . 156 ( 83 % ) of 189 patients with st and ard-risk disease in the auto-allo group and 366 ( 84 % ) of 436 in the auto-auto group received a second transplant . 219 patients in the auto-auto group were r and omly assigned to observation and 217 to receive maintenance treatment , of whom 168 ( 77 % ) completed this treatment . PFS and overall survival did not differ between maintenance and observation groups and pooled data were used . Kaplan-Meier estimates of 3-year PFS were 43 % ( 95 % CI 36 - 51 ) in the auto-allo group and 46 % ( 42 - 51 ) in the auto-auto group ( p=0·671 ) ; overall survival also did not differ at 3 years ( 77 % [ 95 % CI 72 - 84 ] vs 80 % [ 77 - 84 ] ; p=0·191 ) . Within 3 years , 87 ( 46 % ) of 189 patients in the auto-allo group had grade 3 - 5 adverse events as did 185 ( 42 % ) of 436 patients in the auto-auto group . The adverse events that differed most between groups were hyperbilirubinaemia ( 21 [ 11 % ] patients in the auto-allo group vs 14 [ 3 % ] in the auto-auto group ) and peripheral neuropathy ( 11 [ 6 % ] in the auto-allo group vs 52 [ 12 % ] in the auto-auto group ) . INTERPRETATION Non-myeloablative allogeneic HSCT after autologous HSCT is not more effective than t and em autologous HSCT for patients with st and ard-risk multiple myeloma . Further enhancement of the graft versus myeloma effect and reduction in transplant-related mortality are needed to improve the allogeneic HSCT approach . FUNDING US National Heart , Lung , and Blood Institute and the National Cancer Institute
The Hematology DSG noted that the use of transplantation for patients with myeloma varied among practice s across the province .
In terms of survival , is  peripheral blood stem-cell  or  marrow transplantation better than conventional chemotherapy ?
What is the relative efficacy of autologous versus allogeneic transplantation ?
What specifics of the transplantation process can be recommended ?
The addition of interferon is unlikely to influence outcomes in the control group .
In Terms of Survival , Is Autologous Peripheral Blood Stem-Cell or Bone Marrow Transplantation Better than Conventional Chemotherapy ?
After more than three decades of clinical trials testing various st and ard-dose chemotherapy regimens , the disease course of patients with multiple myeloma has not changed appreciably .
Conventional chemotherapy can provide effective palliation but is not curative ( 1 ) .
Case series have described encouraging results in patients with myeloma undergoing allogeneic or autologous bone marrow or peripheral blood stem-cell transplantation ( 2 ) .
Other studies of transplantation , including r and omized trials , have been reported in the past 6 years ( 3 , 4 ) .
To facilitate decisions about treatment options , practice guidelines have been developed for use by health care providers and consumers .
In Ontario , Canada , cancer treatments and policies are led by a state-funded organization , Cancer Care Ontario .
To help derive treatment options , Cancer Care Ontario has developed the Program in Evidence -Based Care , which includes the Practice Guidelines Initiative .
To approach this topic , the DSG addressed the following questions : What is optimal st and ard-dose chemotherapy for patients with myeloma ?
When should transplantation be performed ?
Who should ( or should not ) receive a transplant ?