OpenOnco · Treatment Plan

Treatment plan — Multiple Myeloma

PLAN-BMA-TP53_MUT_MM-V1 · v1 · 2026-08-17

Patient

BMA-TP53_MUT_MM · Algorithm: ALGO-MM-1L

DiagnosisMultiple Myeloma

MOH / ICD-10C90.0

ICD-O-39732/3; C42.1

Clinical significance of mutations (ESCAT)

Tumor-board context — the engine does not use these tiers to rank tracks

Biomarker	Variant	ESCAT	Evidence	Clinical significance	Drugs	Sources
ESCAT: clinical review pendingBIO-TP53-MUTATION	any pathogenic mutation OR del(17p)	IIA	Molecular evidence option SRC-CIVIC: Level A (Supports, Poor Outcome) SRC-CIVIC: Level B (Supports, N/A) Resistance or avoidance signal SRC-CIVIC: Level B ⚠ Resistance SRC-CIVIC: Level C ⚠ Resistance Trial or research option SRC-CIVIC: Level C (Supports, Sensitivity/Response) SRC-CIVIC: Level D (Supports, Sensitivity/Response)	TP53-mut / del(17p) myeloma — high-risk cytogenetics composite; quadruplet (D-VRd; PERSEUS) preferred over triplet. Maintenance with daratumumab/lenalidomide. CAR-T (ide-cel, cilta-cel) effective regardless of TP53 status.	D-VRd (1L transplant-eligible) Dara-Rd (1L transplant-ineligible) ide-cel / cilta-cel (R/R) alloSCT consideration in young high-risk	SRC-NCCN-MM-2025 SRC-ESMO-MM-2023 SRC-EHA-EMN-MM-2025

Primary current-line option

Standard plan

★ DEFAULT

Indication

IND-MM-1L-VRD

Regimen

Bortezomib + Lenalidomide + Dexamethasone (VRd), 4-6 induction cycles

Drugs + NSZU

Bortezomib (DRUG-BORTEZOMIB) 1.3 mg/m² · SC days 1, 8, 15 of each 28-day cycle (weekly schedule for induction) · SC ⚠ NSZU — not for this indication
Lenalidomide (DRUG-LENALIDOMIDE) 25 mg · PO days 1-21 of each 28-day cycle · PO ⚠ NSZU — not for this indication
Dexamethasone (DRUG-DEXAMETHASONE) 40 mg (20 mg if age >75 or frail) · PO days 1, 8, 15, 22 of each 28-day cycle · PO ✓ NSZU covered

Supportive care

SUP-HSV-PROPHYLAXIS, SUP-MM-VTE-PROPHYLAXIS, SUP-MM-BONE-PROTECTION

Hard contraindications

CI-LENALIDOMIDE-PREGNANCY, CI-BORTEZOMIB-SEVERE-NEUROPATHY

Reason

Primary current-line option selected by ALGO-MM-1L at step 3.

Other current-line alternatives (3 tracks)

Same treatment line; review when biomarker, access, contraindication, or patient-context assumptions change.

Aggressive plan

Indication

IND-MM-1L-DVRD

Regimen

Daratumumab + Bortezomib + Lenalidomide + Dexamethasone (D-VRd), 4-6 induction cycles

Drugs + NSZU

Daratumumab (DRUG-DARATUMUMAB) 1800 mg SC (or 16 mg/kg IV) · weekly cycles 1-2 (days 1, 8, 15, 22), every 2 weeks cycles 3-6 (days 1, 15) · SC ⚠ NSZU — not for this indication
Bortezomib (DRUG-BORTEZOMIB) 1.3 mg/m² · SC days 1, 8, 15 of each 28-day cycle · SC ⚠ NSZU — not for this indication
Lenalidomide (DRUG-LENALIDOMIDE) 25 mg · PO days 1-21 of each 28-day cycle · PO ⚠ NSZU — not for this indication
Dexamethasone (DRUG-DEXAMETHASONE) 40 mg (20 mg if age >75 or frail; given before daratumumab as part of premedication) · PO/IV days 1, 8, 15, 22 of each 28-day cycle · PO ✓ NSZU covered

Supportive care

SUP-HSV-PROPHYLAXIS, SUP-MM-VTE-PROPHYLAXIS, SUP-MM-BONE-PROTECTION, SUP-PJP-PROPHYLAXIS

Hard contraindications

CI-LENALIDOMIDE-PREGNANCY, CI-BORTEZOMIB-SEVERE-NEUROPATHY, CI-HBV-NO-PROPHYLAXIS

Reason

Current-line alternative presented for HCP consideration

Standard plan

Indication

IND-MM-1L-RD

Regimen

Lenalidomide + Dexamethasone continuous (Rd, MAIA control arm — MM 1L transplant-ineligible)

Drugs + NSZU

Lenalidomide (DRUG-LENALIDOMIDE) 25 mg PO daily (10 mg if CrCl 30-60 mL/min) · Days 1-21 of each 28-day cycle; continuous until progression · PO ⚠ NSZU — not for this indication
Dexamethasone (DRUG-DEXAMETHASONE) 40 mg PO weekly (20 mg if age >75 or frail) · Days 1, 8, 15, 22 of each 28-day cycle · PO ✓ NSZU covered

Supportive care

SUP-MM-VTE-PROPHYLAXIS, SUP-MM-BONE-PROTECTION

Hard contraindications

CI-LENALIDOMIDE-PREGNANCY

Reason

Current-line alternative presented for HCP consideration

Aggressive plan

Indication

IND-MM-1L-DARA-RD

Regimen

Daratumumab + Lenalidomide + Dexamethasone (D-Rd, MAIA — MM 1L transplant-ineligible)

Drugs + NSZU

Daratumumab (DRUG-DARATUMUMAB) 1800 mg SC (or 16 mg/kg IV) · Weekly cycles 1-2 (days 1, 8, 15, 22); every 2 weeks cycles 3-6 (days 1, 15); every 4 weeks cycle 7+ (day 1) · SC ⚠ NSZU — not for this indication
Lenalidomide (DRUG-LENALIDOMIDE) 25 mg PO daily (10 mg if CrCl 30-60) · days 1-21 of each 28-day cycle · PO ⚠ NSZU — not for this indication
Dexamethasone (DRUG-DEXAMETHASONE) 40 mg PO/IV weekly (20 mg if age >75 or BMI <18.5 or frail) · days 1, 8, 15, 22 of each 28-day cycle · PO ✓ NSZU covered

Supportive care

SUP-HSV-PROPHYLAXIS, SUP-MM-VTE-PROPHYLAXIS, SUP-MM-BONE-PROTECTION, SUP-PJP-PROPHYLAXIS

Hard contraindications

CI-LENALIDOMIDE-PREGNANCY, CI-HBV-NO-PROPHYLAXIS

Reason

Current-line alternative presented for HCP consideration

Pre-treatment investigations

Investigations before treatment start · critical / standard / desired · merged across tracks

ID	Name	Priority	Category	Where to order	Needed for
TEST-BM-ASPIRATE	Bone Marrow Aspirate	Critical	histology	—	all tracks
TEST-BM-TREPHINE	Bone Marrow Trephine	Critical	histology	—	all tracks
TEST-CBC	Complete Blood Count with Differential	Critical	lab	—	all tracks
TEST-CMP	Comprehensive Metabolic Panel	Critical	lab	—	all tracks
TEST-FISH-PANEL	FISH (Fluorescence In Situ Hybridization)	Critical	genomic	CSD Lab ✓ (code TBC)	all tracks
TEST-FREE-LIGHT-CHAINS	Serum Free Light Chains	Critical	lab	—	all tracks
TEST-HBV-SEROLOGY	Hepatitis B Serology Panel (HBsAg, anti-HBc total, anti-HBs)	Critical	lab	—	all tracks
TEST-LDH	Lactate Dehydrogenase	Critical	lab	—	all tracks
TEST-LFT	Liver Function Tests (ALT, AST, bilirubin, ALP, GGT, albumin)	Critical	lab	—	all tracks
TEST-SPEP-UPEP	SPEP / UPEP with IFE	Critical	lab	—	all tracks
TEST-WHOLE-BODY-MRI	Whole-Body MRI	Critical	imaging	—	all tracks
TEST-B2-MICROGLOBULIN	Beta-2 Microglobulin	Standard	lab	—	all tracks
TEST-ECHO	Echocardiography	Standard	imaging	—	aggressive
TEST-IMMUNOGLOBULINS	Quantitative Immunoglobulins	Standard	lab	—	all tracks

Red flags — PRO / CONTRA aggressive

PRO-AGGRESSIVE

Triggers that push toward the aggressive track

Multiple myeloma with ISS stage 3 — β2-microglobulin ≥5.5 mg/L — high-risk presentation; supports four-drug daratumumab-anchored 1L and transplant pursuit when feasible; trigger for R-ISS / R2-ISS upgrade with cytogenetics
ISS-3 (β2M ≥5.5) median OS ~29 mo in the original cohort, improved substantially in the daratumumab era. ISS-3 alone is not a sufficient intensification trigger — cytogenetics drive the upgrade to R-ISS (Palumbo 2015) and R2-ISS…
RF-ISS-3SRC-NCCN-MM-2025SRC-ESMO-MM-2023
Multiple myeloma with malignant epidural spinal cord compression: new motor deficit, sensory level, severe back pain with vertebral plasmacytoma / lytic lesion + canal invasion — MM is a leading hematologic cause of MESCC
Per NCCN-MM + ESMO-MM 2023 + EHA-EMN-MM 2025: dexamethasone 40 mg PO/IV bolus, MRI whole spine, urgent RT (8 Gy ×1 or 20-30 Gy fractionated) ± neurosurgical decompression for instability/large mass; bortezomib- based induction begun in…
RF-MM-CORD-COMPRESSIONSRC-NCCN-MM-2025SRC-ESMO-MM-2023SRC-EHA-EMN-MM-2025
Multiple myeloma high-risk cytogenetics: any of t(4;14), t(14;16), t(14;20), del(17p)/TP53 loss, gain or amplification of 1q21 by interphase FISH on CD138-enriched plasma cells
Primary determinant for selecting quadruplet (D-VRd) over triplet (VRd) in transplant-eligible newly-diagnosed MM. R2-ISS captures most of these abnormalities; gain 1q21 is graded by copy count (≥4 copies = amp1q carries higher risk than…
RF-MM-HIGH-RISK-CYTOGENETICSSRC-NCCN-MM-2025SRC-ESMO-MM-2023
Multiple myeloma with hypercalcemia (corrected serum calcium ≥11 mg/dL or symptomatic): part of CRAB criteria; emergency when ≥14 mg/dL or symptomatic (altered mentation, AKI, arrhythmia)
Hypercalcemia is one of CRAB criteria for MM diagnosis; per ESMO-MM 2023 + NCCN-MM: aggressive IV hydration (3-4 L NS/24h), zoledronic acid 4 mg IV (renal-adjusted) or denosumab 120 mg SC; calcitonin 4 IU/kg SC q12h for first 24-48h while…
RF-MM-HYPERCALCEMIASRC-NCCN-MM-2025SRC-ESMO-MM-2023SRC-EHA-EMN-MM-2025
Multiple myeloma with hyperviscosity syndrome — uncommon but classic in IgA-MM (M-spike >5 g/dL, polymerization tendency) or biclonal gammopathy: blurred vision, retinal hemorrhage, mucosal bleeding, neurologic symptoms
Hyperviscosity is much rarer in MM than WM (IgM is intrinsically more viscous than IgG/IgA), but IgA-MM with very high M-spike (>5 g/dL) or biclonal disease can produce it. Per NCCN-MM + ESMO-MM 2023: plasmapheresis 1-2 plasma volumes…
RF-MM-HYPERVISCOSITYSRC-NCCN-MM-2025SRC-ESMO-MM-2023
Aggressive plasma-cell biology indicating need for intensified MM induction: plasma cell leukemia (≥5% circulating plasma cells, or absolute count ≥500/µL), extramedullary disease at diagnosis (soft-tissue plasmacytoma not contiguous with bone), or rapid laboratory progression (≥25% rise in M-protein over 4-8 weeks pre-treatment).
Plasma cell leukemia (PCL) — both primary and secondary forms have inferior PFS/OS on standard VRd; D-VRd or KCd is preferred. EMD at diagnosis (soft-tissue plasmacytoma not extending from bone): ≈30% worse PFS regardless of cytogenetics…
RF-MM-TRANSFORMATION-PROGRESSIONSRC-NCCN-MM-2025SRC-ESMO-MM-2023
Multiple myeloma with R-ISS stage 3 — ISS-3 (β2M ≥5.5) PLUS LDH above ULN PLUS high-risk cytogenetics by FISH (any of t(4;14), t(14;16), del(17p)) — most aggressive presentation; supports four-drug D-VRd induction + ASCT (eligible) or D-Rd intensification (unfit) + maintenance
R-ISS (Palumbo et al., JCO 2015) refined ISS by adding LDH and FISH cytogenetics: R-ISS-3 = ISS-3 + LDH-high + high-risk FISH. R-ISS-3 median OS ~43 mo pre-daratumumab; modern PERSEUS / IsKia / GRIFFIN show D-VRd benefits across risk…
RF-R-ISS-3-HIGH-RISKSRC-NCCN-MM-2025SRC-ESMO-MM-2023

CONTRA-AGGRESSIVE

Hard contraindications to escalation

Lenalidomide is a potent teratogen — pregnancy is an absolute contraindication. Adequate contraception (two methods) and pregnancy testing are mandatory throughout therapy and for ≥4 weeks after discontinuation.CI-LENALIDOMIDE-PREGNANCY
Severe pre-existing peripheral neuropathy is an absolute contraindication to bortezomib — therapy will likely worsen the neuropathy to a disabling and often permanent extent.CI-BORTEZOMIB-SEVERE-NEUROPATHY
Active or latent HBV without antiviral prophylaxis is an absolute contraindication to starting B-cell-depleting / immunomodulatory monoclonal antibody therapy (anti-CD20, anti-CD30 ADC, anti-CD38). Severe HBV reactivation hepatitis risk including fulminant hepatic failure.CI-HBV-NO-PROPHYLAXIS
Lenalidomide is a potent teratogen — pregnancy is an absolute contraindication. Adequate contraception (two methods) and pregnancy testing are mandatory throughout therapy and for ≥4 weeks after discontinuation.CI-LENALIDOMIDE-PREGNANCY
Active or latent HBV without antiviral prophylaxis is an absolute contraindication to starting B-cell-depleting / immunomodulatory monoclonal antibody therapy (anti-CD20, anti-CD30 ADC, anti-CD38). Severe HBV reactivation hepatitis risk including fulminant hepatic failure.CI-HBV-NO-PROPHYLAXIS

What NOT to do

Explicit prohibitive rules, each grounded in a regimen / supportive care / contraindication entity

Standard plan (IND-MM-1L-VRD)

Do not skip VTE prophylaxis (aspirin 81-100 mg or LMWH) — baseline thrombosis risk on lenalidomide is 10-20%, with prophylaxis falls to 2-5%.
Do not skip HSV/VZV prophylaxis (acyclovir 400 mg BID) during proteasome inhibitor — ~10-15% herpes zoster reactivation without prophylaxis.
Do not use IV bortezomib if SC is available — frequency of severe neuropathy is approximately twice as high with IV administration.
Do not start regimen in women of reproductive age without confirmed two methods of contraception + negative pregnancy test (lenalidomide is a potent teratogen).
Do not prescribe zoledronate without prior dental evaluation — risk of osteonecrosis of the jaw.
Do not skip lenalidomide dose reduction at CrCl 30-60 mL/min (10 mg) — full dose is toxic with renal impairment.

Aggressive plan (IND-MM-1L-DVRD)

Do not prescribe daratumumab without prior red-cell phenotyping (type and screen) — anti-CD38 interferes with direct Coombs and crossmatching.
Do not start without HBV screening + entecavir prophylaxis in HBsAg+ or anti-HBc+ — risk of HBV reactivation significantly elevated on anti-CD38.
Do not confirm D-VRd plan without verified funding pathway — daratumumab is NOT reimbursed via NSZU; the patient must be informed before the plan is announced.
Do not skip VTE prophylaxis (aspirin/LMWH) — IMiD-induced VTE risk is not reduced by adding daratumumab.
Do not skip HSV/VZV prophylaxis — bortezomib + dara combination increases immunosuppression.
Do not skip PJP prophylaxis — anti-CD38 + IMiD + steroid = elevated risk of opportunistic infections.
Do not start in women of reproductive age without two methods of contraception (lenalidomide is teratogenic).

Standard plan (IND-MM-1L-RD)

Do not skip VTE prophylaxis (aspirin 81-100 mg or LMWH) — IMiD-induced VTE risk 10-20% without prophylaxis.
Do not skip HSV/VZV prophylaxis (acyclovir 400 mg BID) — IMiD + steroid elevates herpes zoster reactivation risk.
Do not start in women of reproductive age without two methods of contraception + negative pregnancy test (lenalidomide is teratogenic).
Do not skip lenalidomide dose reduction at CrCl 30-60 mL/min (use 10 mg) — full dose significantly toxic in renal impairment.
Do not prescribe zoledronate without prior dental evaluation — osteonecrosis of the jaw risk.
Do not use IND-MM-1L-RD if daratumumab is funded — aggressive plan (IND-MM-1L-DARA-RD) has superior survival outcomes.

Aggressive plan (IND-MM-1L-DARA-RD)

Do not prescribe daratumumab without prior red-cell phenotyping (type and screen) — anti-CD38 interferes with direct Coombs and crossmatching.
Do not start without HBV screening + entecavir prophylaxis in HBsAg+ or anti-HBc+ — risk of HBV reactivation significantly elevated on anti-CD38.
Do not confirm D-Rd plan without verified funding pathway — daratumumab is NOT reimbursed via NSZU; patient must be informed before the plan is announced.
Do not skip VTE prophylaxis (aspirin/LMWH) — IMiD-induced VTE risk is not reduced by adding daratumumab.
Do not skip HSV/VZV prophylaxis — daratumumab adds to lenalidomide immunosuppression.
Do not skip PJP prophylaxis — anti-CD38 + IMiD + steroid = elevated risk of opportunistic infections.
Do not start in women of reproductive age without two methods of contraception (lenalidomide is teratogenic).
Do not use in transplant-eligible patients — D-VRd (IND-MM-1L-DVRD) is the appropriate plan for transplant-eligible patients.
Do not reduce dexamethasone without clinical indication in first 6 cycles — steroid dose reduction at this point may reduce anti-CD38 efficacy.

Monitoring schedule

Monitoring schedule by treatment phase

Standard plan · MON-VRD-REGIMEN

Phase	Window	Tests	Checkpoints
Baseline	Within 2 weeks before cycle 1	TEST-CBC, TEST-CMP, TEST-LFT, TEST-LDH, TEST-B2-MICROGLOBULIN, TEST-IMMUNOGLOBULINS, TEST-SPEP-UPEP, TEST-FREE-LIGHT-CHAINS, TEST-HBV-SEROLOGY, TEST-FISH-PANEL, TEST-BM-ASPIRATE, TEST-BM-TREPHINE, TEST-WHOLE-BODY-MRI, TEST-ECHO	Confirm CD138+ plasma cell percentage and FISH cytogenetic risk category R-ISS / R2-ISS staging documented Confirm HBV status and prophylaxis plan if anti-CD38 or anti-CD20 in regimen Dental evaluation before zoledronate / denosumab Red-cell phenotyping BEFORE first daratumumab dose
On treatment	Day 1 of every 28-day cycle + mid-cycle CBC for high-risk patients	TEST-CBC, TEST-CMP, TEST-LFT, TEST-FREE-LIGHT-CHAINS, TEST-SPEP-UPEP	ANC ≥ 1000/µL and platelets ≥ 75K before each cycle (delay or reduce otherwise) Neuropathy grade documented at each visit (NCCN/CTCAE) Renal function trend (lenalidomide dose adjustment if CrCl drops) Glucose monitoring for steroid-induced hyperglycemia
Response assessment	After cycles 2 and 4 (before transplant) or every 2-3 cycles (transplant-ineligible)	TEST-FREE-LIGHT-CHAINS, TEST-SPEP-UPEP, TEST-IMMUNOGLOBULINS, TEST-BM-ASPIRATE, TEST-WHOLE-BODY-MRI	IMWG response criteria (sCR, CR, VGPR, PR, MR, SD, PD) MRD assessment by flow cytometry or NGS at suspected CR If <PR after cycle 2 → consider regimen change or trial enrollment
Post-transplant consolidation	Cycles 5-6 post-transplant (transplant-eligible only)	TEST-CBC, TEST-CMP, TEST-FREE-LIGHT-CHAINS, TEST-SPEP-UPEP	Recovery of counts post-transplant before consolidation start Confirm depth of response before starting maintenance
Maintenance	Lenalidomide 10-15 mg daily until progression or intolerance	TEST-CBC, TEST-CMP, TEST-FREE-LIGHT-CHAINS, TEST-SPEP-UPEP	Surveillance for second primary malignancies (annual skin / GU exam) Lenalidomide dose adjustment if cytopenias or worsening renal function Annual influenza + pneumococcal vaccination (non-live only)
Progression monitoring	On clinical or biochemical progression	TEST-FREE-LIGHT-CHAINS, TEST-SPEP-UPEP, TEST-BM-ASPIRATE, TEST-FISH-PANEL, TEST-WHOLE-BODY-MRI	IMWG progression criteria (>25% increase in M-protein, new lytic lesions, hypercalcemia, etc.) Re-do FISH on relapse — high-risk clones may emerge

Timeline

Treatment timeline — derived from regimen + monitoring schedule

Standard plan

Baseline

Within 2 weeks before cycle 1

Induction · Bortezomib + Lenalidomide + Dexamethasone (VRd), 4-6 induction cycles

28-day cycles × 4 cycles before stem-cell harvest (transplant-eligible) OR 8-12 cycles total (transplant-ineligible)

Response assessment

After cycles 2 and 4 (before transplant) or every 2-3 cycles (transplant-ineligible)

Maintenance

Lenalidomide 10-15 mg daily until progression or intolerance

Aggressive plan

Baseline

Within 2 weeks before cycle 1

Induction · Daratumumab + Bortezomib + Lenalidomide + Dexamethasone (D-VRd), 4-6 induction cycles

28-day cycles × 4 cycles before stem-cell harvest (transplant-eligible) OR 6 cycles induction + maintenance (transplant-ineligible per MAIA-style schedule)

Response assessment

After cycles 2 and 4 (before transplant) or every 2-3 cycles (transplant-ineligible)

Maintenance

Lenalidomide 10-15 mg daily until progression or intolerance

Standard plan

Baseline

Within 2 weeks before cycle 1

Induction · Lenalidomide + Dexamethasone continuous (Rd, MAIA control arm — MM 1L transplant-ineligible)

28-day cycles × Continuous until progression or unacceptable toxicity

Response assessment

After cycles 2 and 4 (before transplant) or every 2-3 cycles (transplant-ineligible)

Maintenance

Lenalidomide 10-15 mg daily until progression or intolerance

Aggressive plan

Baseline

Within 2 weeks before cycle 1

Induction · Daratumumab + Lenalidomide + Dexamethasone (D-Rd, MAIA — MM 1L transplant-ineligible)

28-day cycles × Continuous until progression or unacceptable toxicity

Response assessment

After cycles 2 and 4 (before transplant) or every 2-3 cycles (transplant-ineligible)

Maintenance

Lenalidomide 10-15 mg daily until progression or intolerance

MDT brief

Discussion questions (1, 0 blocking)

OQ-LDH-CURRENT
What is the current LDH? Marker of tumor burden and transformation.
LDH is part of the prognostic indices of indolent lymphomas.
→ hematologist

MDT talk tree (2 steps)

#	Owner	Topic	Action
1	hematologist	Staging / disease burden	What is the current LDH? Marker of tumor burden and transformation.
2	clinical_pharmacist	Specialist review	Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.

Skills (recommended) — for consideration (1)

Clinical pharmacist recommended
Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.

Data quality

Usable with caveats. No critical default-track gap was found, but the MDT should review the listed caveats before final sign-off.

Biomarker coverage: 2/2 known (100%), 0 missing, 0 default-track gaps
Unevaluated RedFlags: RF-ISS-1, RF-ISS-3, RF-MM-BCMA-EXPRESSION-POS, RF-MM-CD38-EXPRESSION-DARA-CANDIDATE, RF-MM-CORD-COMPRESSION, RF-MM-FRAILTY-AGE, RF-MM-HIGH-RISK-CYTOGENETICS, RF-MM-HYPERCALCEMIA, RF-MM-HYPERVISCOSITY, RF-MM-INFECTION-SCREENING, RF-MM-RENAL-DYSFUNCTION, RF-MM-T11-14-ACTIONABLE, RF-MM-TRANSFORMATION-PROGRESSION, RF-R-ISS-3-HIGH-RISK

Technical MDT skill metadata (1/16 activated in this plan)

All registered virtual specialists. ✓ — activated for this case; ○ — not activated (available for other clinical scenarios).

Specialist	skill_id	Version	Last reviewed	Domain
Cellular therapy specialist (CAR-T)	`cellular_therapy_specialist`	v0.1.0	2026-04-25	cellular_therapy
Clinical pharmacist	`clinical_pharmacist`	v0.1.0	2026-04-25	clinical_pharmacy
Hematologist / oncohematologist	`hematologist`	v0.1.0	2026-04-25	hematology_oncology
Hematopathologist (lymphoma / leukemia / myeloma)	`hematopathologist`	v0.1.0	2026-04-25	hematopathology
Infectious disease / hepatology	`infectious_disease_hepatology`	v0.1.0	2026-04-25	infectious_diseases
Medical oncologist (solid-tumor chemotherapist)	`medical_oncologist`	v0.1.0	2026-04-25	solid_oncology
Molecular geneticist / molecular oncologist	`molecular_geneticist`	v0.1.0	2026-04-25	molecular_oncology
Palliative care	`palliative_care`	v0.1.0	2026-04-25	palliative_care
Pathologist (general)	`pathologist`	v0.1.0	2026-04-25	pathology
Primary care / family physician	`primary_care`	v0.1.0	2026-04-25	primary_care
Psycho-oncologist	`psychologist`	v0.1.0	2026-04-25	psychosocial
Radiation oncologist	`radiation_oncologist`	v0.1.0	2026-04-25	radiation_oncology
Radiologist	`radiologist`	v0.1.0	2026-04-25	diagnostic_imaging
Social worker / case manager	`social_worker_case_manager`	v0.1.0	2026-04-25	psychosocial
Surgical oncologist	`surgical_oncologist`	v0.1.0	2026-04-25	surgical_oncology
Transplant specialist (BMT)	`transplant_specialist`	v0.1.0	2026-04-25	cellular_therapy

Sources cited

SRC-GRIFFIN-VOORHEES-2020: Daratumumab, lenalidomide, bortezomib, and dexamethasone for transplant-eligible newly diagnosed multiple myeloma (GRIFFIN) (2020)
SRC-MAIA-FACON-2019: Daratumumab plus Lenalidomide and Dexamethasone for Untreated Myeloma (2019)
SRC-NCCN-MM-2025: NCCN Clinical Practice Guidelines in Oncology: Multiple Myeloma (v.X.2025)
SRC-PERSEUS-SONNEVELD-2024: Daratumumab, Bortezomib, Lenalidomide, and Dexamethasone for Multiple Myeloma (2024)

Experimental options (clinical trials)

Third plan track — open-enrollment trials from ClinicalTrials.gov. Render-time metadata; engine selection is not affected by this block (CHARTER §8.3). Last synced: 2026-08-17.

NCT	Title	Phase	Status	Sponsor	UA	Signals
NCT07284758	A Study to Evaluate the Efficacy of Cemsidomide + Dexamethasone in Participants With Relapsed/Refractory Multiple Myeloma	PHASE2	RECRUITING	C4 Therapeutics, Inc.	—	Surrogate endpoint only
NCT06758713	Safety and Efficacy of Fourth-Generation CAR-T in the Treatment of Hematologic Malignancies	PHASE1	RECRUITING	The Third Affiliated Hospital of Southern Medical University	—	Phase 1 only Surrogate endpoint only Single country
NCT06514508	Mobilization of Stem Cells With Motixafortide (BL-8040) in Combination With G-CSF in Multiple Myeloma Patients	PHASE3	RECRUITING	Guangzhou Gloria Biosciences Co., Ltd.	—	Single country
NCT03937635	Lenalidomide, and Dexamethasone With or Without Daratumumab in Treating Patients With High-Risk Smoldering Myeloma	PHASE3	RECRUITING	ECOG-ACRIN Cancer Research Group	—	—
NCT04898790	Improving Cognitive Function in Older Adults Undergoing Stem Cell Transplant	NA	RECRUITING	University of Nebraska	—	Single country
NCT03702309	Liquid Biopsy Evaluation and Repository Development at Princess Margaret	N/A	RECRUITING	University Health Network, Toronto	—	Single country
NCT04662294	CD 70 CAR T for Patients With CD70 Positive Malignant Hematologic Diseases	EARLY_PHASE1	RECRUITING	Zhejiang University	—	Single country
NCT02343042	Selinexor and Backbone Treatments of Multiple Myeloma Patients	PHASE1 / PHASE2	RECRUITING	Karyopharm Therapeutics Inc	—	Surrogate endpoint only
NCT07044427	Fall Risk Assessment and an Exercise Intervention for Prevention of Falls in Multiple Myeloma Patients	NA	RECRUITING	University Hospital Heidelberg	—	Single country
NCT07268846	Use of Preoperative Postbiotic Supplementation in Colorectal Cancer Surgery	NA	RECRUITING	AC Camargo Cancer Center	—	Single country

Verify recruitment status directly with the trial site. ctgov data can lag behind current UA-site status.

Option availability in Ukraine

Per-track UA registration · NSZU · cost · access pathway. Render-time metadata; engine selection does not depend on these fields (CHARTER §8.3).

Option	UA registration	NSZU	Cost orientation	Access pathway
Standard plan Bortezomib + Lenalidomide + Dexamethasone (VRd), 4-6 induction cycles (REG-VRD)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Aggressive plan Daratumumab + Bortezomib + Lenalidomide + Dexamethasone (D-VRd), 4-6 induction cycles (REG-DARA-VRD)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Standard plan Lenalidomide + Dexamethasone continuous (Rd, MAIA control arm — MM 1L transplant-ineligible) (REG-RD-CONTINUOUS)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Aggressive plan Daratumumab + Lenalidomide + Dexamethasone (D-Rd, MAIA — MM 1L transplant-ineligible) (REG-D-RD-MAIA)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Trial · NCT07284758 A Study to Evaluate the Efficacy of Cemsidomide + Dexamethasone in Participants With Relapsed/Refractory Multiple Myeloma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06758713 Safety and Efficacy of Fourth-Generation CAR-T in the Treatment of Hematologic Malignancies No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06514508 Mobilization of Stem Cells With Motixafortide (BL-8040) in Combination With G-CSF in Multiple Myeloma Patients No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT03937635 Lenalidomide, and Dexamethasone With or Without Daratumumab in Treating Patients With High-Risk Smoldering Myeloma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT04898790 Improving Cognitive Function in Older Adults Undergoing Stem Cell Transplant No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT03702309 Liquid Biopsy Evaluation and Repository Development at Princess Margaret No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT04662294 CD 70 CAR T for Patients With CD70 Positive Malignant Hematologic Diseases No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT02343042 Selinexor and Backbone Treatments of Multiple Myeloma Patients No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07044427 Fall Risk Assessment and an Exercise Intervention for Prevention of Falls in Multiple Myeloma Patients No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07268846 Use of Preoperative Postbiotic Supplementation in Colorectal Cancer Surgery No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor

Cost information is orientation. Verify with a specific pharmacy / foundation / trial site. Status updated: 2026-08-17.

plan_id: PLAN-BMA-TP53_MUT_MM-V1 | version: 1 | generated: 2026-08-17T08:06:32.179044+00:00

Per FDA non-device CDS positioning (CHARTER §15): Outpatient oncology treatment planning to support tumor-board discussion. Not a medical device; not for autonomous clinical decision-making.

Per FDA non-device CDS positioning (CHARTER §15): Both treatment options below are presented for review. The engine's selection of a 'recommended' default does not constitute a clinical decision. Final treatment selection requires HCP judgment incorporating information not available to the system.

This document is an informational resource supporting tumor-board discussion (per CHARTER §11). It is not a system that makes clinical decisions. Every recommendation must be verified by the treating physician.