How do you approach treatment for a patient with a biochemical relapse while on maintenance lenalidomide after autologous stem cell transplant for multiple myeloma?

Biochemical relapse (i.e. increase in M-spike or light chains meeting criteria for progression on two occasions without clinical progression) is an indication for starting treatment in my opinion. I have seen some recommend increasing the dose of lenalidomide to 25 mg in the hopes this will bring disease back under control, but I do not think this is a sound strategy. These patients should be considered to be lenalidomide refractory.

For the purposes of this answer, I will assume most patients had VRd upfront.

The next question is how long ago was the transplant, or did they receive a transplant at all. I would pursue re-induction followed by ASCT as second line therapy in transplant-eligible patients if:

• They never had an ASCT upfront.
• T...