Dr Chari on Frontline Combinations and Transplant Approaches in Multiple Myeloma

Quadruplets are great, but because their efficacy is so good, the question is: Are we ready to forego ASCT? I don’t think we have a clear answer for that yet.

Ajai Chari, MD, a professor of medicine and director of the Multiple Myeloma Program at the University of California, San Francisco, discussed the evolving role of quadruplet combination therapies in the treatment of patients with newly diagnosed multiple myeloma, along with transplant considerations for this patient population.

Regarding frontline treatment approaches, Chari explained that consensus strongly supported the use of quadruplet regimens over triplet therapies, based on multiple phase 3 data readouts for these types of combinations. Despite the often wide range of opinions among myeloma specialists, agreement on this approach was clear during Bridging the Gaps 2025. However, he emphasized an important nuance: it remained uncertain whether frail or older patients would benefit equally from quadruplet regimens, highlighting an area in need of further clarification.

Chari also addressed the evolving role of autologous stem cell transplant (ASCT) in the era of highly effective frontline combination therapies. Although quadruplet regimens have produced impressive outcomes, he stated that there was not yet sufficient evidence to support routinely omitting ASCT. Instead, Chari emphasized that all eligible patients should still be considered for transplant, noting that many of the strongest results seen with quadruplet induction were achieved in conjunction with ASCT.

Additionally, Chari pointed out practical considerations for clinicians, including the fact that real-world use of bortezomib (Velcade) often differs from clinical trial protocols, with reduced frequency of dosing typically used in clinical practice. He further highlighted ongoing discussions regarding the role of maintenance therapy, explaining that although long progression-free survival has been observed with current strategies, there is growing interest in limiting maintenance duration. Chari noted that the group supported exploring discontinuation of maintenance therapy, particularly in standard-risk patients who achieve sustained minimal residual disease negativity, rather than continuing indefinite treatment.

See more of Chari’s insights on key consensus viewpoints in multiple myeloma, stemming from the publication of recommendations from the 2025 Bridging the Gaps in Leukemia, Lymphoma, and Multiple Myeloma Conference.