Lenalidomide maintenance in myeloma

We strongly agree with Rajkumar (Haematological cancer: Lenalidomide maintenance—perils of a premature denouement. Nat. Rev. Clin. Oncol. 9, 372–374; 2012)1 that it is premature to recommend lenalidomide maintenance to all patients with myeloma, but we would also like to underline other aspects of the problem not discussed in the recent commentary article. It is our assertion that not every patient with myeloma needs maintenance therapy. In addition to considering the risk–benefit ratio for a patient during maintenance therapy, we are convinced that the wellknown concept of disease plateau—which was established decades before the novelagent era in myeloma2—is also applicable in the setting of maintenance ther apy. Furthermore, a small percentage of patients (15%, but this could improve with novel agents used in the pre- transplant setting) after autologous stem-cell transplantation (ASCT) achieve disease-free survival or progression-free survival of longer than 10 years.3 For those patients, any maintenance therapy is useless or, even worse, harmful.