This medical-professional review synthesizes current guidelines and real-world data to contrast how multiple myeloma (MM) is treated in the United States and China today. It focuses on standard-of-care (SOC) by line and transplant eligibility, typical care pathways from induction through maintenance, and the practical access constraints that often determine what patients actually receive.
1) Standards of care by line of therapy
United States (guidelines and pivotal trials)
- Transplant-eligible newly diagnosed MM (NDMM): Daratumumab plus bortezomib, lenalidomide, and dexamethasone (daratumumab-VRd, D-VRd) is a preferred induction regimen per NCCN 2025, based on PERSEUS (n=709). Four cycles of induction followed by autologous transplant (ASCT), two cycles of consolidation, and maintenance (lenalidomide vs daratumumab+lenalidomide). At 47.5 months, D-VRd reduced the risk of progression or death by 58% versus VRd (HR 0.42; P<.001), with higher complete response (CR) and minimal residual disease (MRD) negativity rates; grade 3–4 neutropenia and thrombocytopenia were more frequent with daratumumab 1. NCCN also lists isatuximab/carfilzomib/lenalidomide/dexamethasone (Isa-KRd) as useful in certain circumstances (higher MRD negativity after induction and consolidation) 2. ASCO–Ontario Health and EHA–EMN guidelines converge on quadruplet induction and high-dose melphalan ASCT for fit candidates; lenalidomide maintenance is standard and daratumumab+lenalidomide maintenance is increasingly supported by randomized data (e.g., PERSEUS) 2830.
- Transplant-ineligible NDMM: Isatuximab-VRd (Isa-VRd) is listed by NCCN as a preferred option for selected transplant-ineligible patients based on the IMROZ study and subsequent regulatory approval; regimen selection should also consider frailty, comorbidity burden, and treatment tolerance 212. Alternatives include daratumumab–lenalidomide–dexamethasone (DRd) or VRd in patients unable to tolerate quadruplets 230.
- Relapsed/refractory MM (RRMM): Triplets incorporating anti-CD38 antibodies with proteasome inhibitors (PIs) or immunomodulatory drugs (IMiDs) are a mainstay; BCMA-directed therapies (CAR-T and bispecific antibodies) are integrated for later lines per contemporary guidelines 22830. In the United States, idecabtagene vicleucel and ciltacabtagene autoleucel are approved BCMA CAR-Ts; teclistamab and elranatamab are approved BCMA bispecific antibodies 10. CMS provides coverage pathways for approved CAR-T therapies when administered at qualified centers under REMS requirements, although real-world access may still be affected by referral patterns, center availability, manufacturing timelines, and patient cost-sharing 20.
China (guidelines and consensus)
- Transplant-eligible NDMM: The 2025 CSCO Hematopoietic Stem Cell Transplantation guidelines recommend triplet or quadruplet induction (e.g., VRd; daratumumab- or isatuximab-containing quadruplets) for 3–6 cycles, stem cell mobilization/collection, and ASCT, followed by maintenance ≥2 years. High-risk cytogenetics favor dual-drug maintenance (IMiD + PI or IMiD + anti-CD38 mAb) over monotherapy. Salvage ASCT is considered at relapse when prior PFS >2 years. These recommendations align with the 2021 Chinese auto-HSCT guidance that emphasizes early ASCT (≤1 year from diagnosis) for patients with persistent MRD positivity after induction and careful regimen tailoring for organ dysfunction [CSCO 2025 and 2021 Chinese auto-HSCT guidance; no numeric citation in retrieved materials].
- Transplant-ineligible NDMM: CSCO emphasizes triplets/quadruplets analogous to U.S. practice, with dose attenuation for frail patients. A 2024 national high-risk MM consensus recommends CD38 mAb–based quadruplets (Dara/Isa with VRd or KRd) and considers tandem ASCT for fit high-risk patients; for transplant-ineligible high-risk disease, fit/intermediate-fit patients receive the same quadruplets; frail patients may receive VRd-lite or DRd 8.
- RRMM: CSCO highlights re-induction and salvage ASCT where feasible; anti-CD38 mAb combinations with PIs/IMiDs are central. Domestic and imported BCMA CAR-T therapies exist but routine access is limited to specialized centers and pilot programs; clinical trial enrollment is encouraged 810.
2) Typical care pathways and real-world patterns
United States
- Transplant-eligible NDMM: D-VRd induction (4 cycles), ASCT with high-dose melphalan, two cycles of consolidation, and maintenance—often lenalidomide, with increasing use of daratumumab+lenalidomide; MRD-guided daratumumab discontinuation after ≥24 months in sustained MRD-negative CR is used in PERSEUS 1. Real-world (2016–2022) data show patients who receive ASCT in first line achieve much longer PFS (median 52.7 vs 19.9 months; adjusted HR 0.49) and better OS versus non-ASCT, with consistent benefit across older age, renal impairment, and high-risk cytogenetics; most receive IMiD maintenance afterward 4. Lenalidomide maintenance post-ASCT improves PFS and 3-year OS in community settings (Connect MM) 27.
- Transplant-ineligible NDMM: Isa-VRd is preferred in non-frail patients per NCCN and FDA approval; DRd or VRd are alternatives where quadruplets are unsuitable 212. Adoption of triplets has steadily improved real-world outcomes compared with doublets in earlier periods 26.
- RRMM: Anti-CD38 triplets (e.g., Dara-Pd, DVd, DKd) and carfilzomib-based options are used per prior exposures, with BCMA CAR-T or bispecifics integrated for lenalidomide-refractory disease; access is supported by FDA approvals and CMS coverage 10202830.
China
- Transplant-eligible NDMM: CSCO recommends induction with triplet/quadruplet regimens and early ASCT; however, utilization is variable by age, center capacity, and referral logistics. A two-decade real-world analysis reported higher recorded frontline ASCT utilization in the analyzed Chinese cohort than in the analyzed U.S. cohort, although cross-country comparisons should be interpreted cautiously because of differences in datasets, referral patterns, age structure, and treatment selection. But it drops sharply in patients ≥65 years (6.7% vs 12.1%), suggesting age-based selection and access constraints in older adults 29. National registry data confirm rapid growth of HSCT capacity (6,659 ASCTs in 2023 across 212 transplant teams) but centered in large provinces, reinforcing urban–rural access disparities 31.
- Transplant-ineligible NDMM: VRd remains a common backbone; quadruplets are increasing at tertiary centers. Real-world geriatric cohorts show higher response with PI+IMiD regimens and substantial survival benefit when any maintenance is used; yet ~30% of responders forgo maintenance, and treatment duration is often shorter due to cost/tolerability 6.
- RRMM: Anti-CD38 therapies are used predominantly in second line and later (first-line daratumumab use 16.5% in a 2023 multicenter registry), with higher response when used earlier; ASCT during/after daratumumab occurs infrequently (10.4%) 7. BCMA CAR-T access is limited to designated centers and pilot programs; out-of-pocket costs remain substantial, and wait times/logistics constrain utilization 111516171819.
3) Access and availability constraints
Proteasome inhibitors (PIs) and immunomodulatory drugs (IMiDs)
- United States: Bortezomib, carfilzomib, ixazomib, lenalidomide, and pomalidomide are approved and broadly reimbursed, enabling wide triplet/quadruplet use in community practice 10.
- China: Bortezomib and lenalidomide are widely used; NRDL negotiations (2023–2025) have reduced IMiD costs substantially (e.g., lenalidomide price reduction after 2023 patent expiry and procurement), improving frontline access and maintenance feasibility, though adherence gaps remain in practice 1516171819. Pomalidomide and carfilzomib access is improving but remains more variable than in the U.S. 10.
Anti-CD38 monoclonal antibodies
- United States: Daratumumab and isatuximab are approved across settings; D-VRd (TE NDMM) and Isa-VRd (TI NDMM) have recent FDA approvals, accelerating frontline adoption 1213.
- China: Daratumumab (2019 approval in RRMM) has diffused into earlier lines more slowly; isatuximab received NMPA approval in January 2025 for use with pomalidomide-dexamethasone after ≥1 prior line—expanding options in RRMM. Frontline anti-CD38 quadruplets are increasing at academic centers, but provincial reimbursement and infusion capacity limit routine use 79111516171819.
BCMA-directed therapies
- United States: Idecabtagene vicleucel and ciltacabtagene autoleucel are approved CAR-T options; teclistamab and elranatamab are approved bispecifics. CMS covers CAR-T under an NCD when delivered at qualified centers (REMS), supporting integration into later lines; site-of-care billing pathways (Part A/B) and NTAP facilitate hospital adoption 1020.
- China: Multiple BCMA CAR-Ts are approved domestically (e.g., ciltacabtagene autoleucel, equecabtagene autoleucel, zevorcabtagene autoleucel per dataset), and teclistamab is listed as approved in China in the dataset; however, real-world access remains limited to designated centers and pilot programs (e.g., Hainan Boao Lecheng), with substantial out-of-pocket costs (often tens of thousands of USD) and variable provincial support 10111516171819. No center-level counts or wait-time metrics were found in the retrieved materials.
4) Standardized China–United States comparison table
| Treatment setting/line | Transplant eligibility | United States standard-of-care | China standard-of-care | Access constraints | Practical notes |
|---|---|---|---|---|---|
| NDMM induction | Transplant-eligible | D-VRd ×4 cycles preferred (PERSEUS), then ASCT; Isa-KRd useful in certain circumstances 12 | Triplets/quadruplets (VRd; Dara/Isa-based) ×3–6 cycles per CSCO; early ASCT recommended; tandem ASCT considered for high-risk per consensus 8 | China anti-CD38 formulary/reimbursement variable; infusion capacity centered in tertiary hospitals | PERSEUS: D-VRd improved PFS and MRD negativity vs VRd; higher grade 3–4 cytopenias with daratumumab 1 |
| NDMM induction | Transplant-ineligible | Isa-VRd preferred if non-frail <80 (IMROZ; FDA 2024); DRd or VRd if quadruplets unsuitable 212 | VRd commonly used; quadruplets increasing at major centers; DRd for frail/intolerant patients 8 | Quadruplet affordability and infusion capacity limit broad use in China | IMROZ: ~40% risk reduction vs VRd; better MRD negativity with Isa-VRd 2 |
| ASCT and consolidation | Transplant-eligible | High-dose melphalan ASCT; some centers give 2 cycles consolidation (same backbone) 12830 | ASCT standard for eligible patients, but utilization lower in ≥65; consolidation used selectively [CSCO 2025; 2021 Chinese auto-HSCT guidance] | China ASCT concentrated in large centers; referral logistics and age-based selection limit use in older adults 2931 | U.S. real-world ASCT in 1L improves PFS and OS vs non-ASCT across subgroups 4 |
| Maintenance (post-ASCT) | Transplant-eligible | Lenalidomide standard; daratumumab+lenalidomide increasingly used; MRD-guided daratumumab discontinuation in sustained MRD-negative CR in PERSEUS 12830 | Lenalidomide- or bortezomib-based maintenance is commonly used after ASCT in China; intensified or combination maintenance strategies may be considered in selected high-risk patients at specialized centers; ≥2 years recommended [CSCO 2025] | Daratumumab maintenance constrained by cost and infusion resources; lenalidomide access improved post-NRDL price cuts 1516171819 | Lenalidomide maintenance improves PFS/OS in U.S. community practice (Connect MM) 27 |
| Maintenance (non-transplant) | Transplant-ineligible | Continuous lenalidomide-based therapy; consider anti-CD38 combinations in selected patients 230 | Lenalidomide or bortezomib maintenance preferred over thalidomide, especially in high-risk disease; duration often <24 months in practice 246 | Cost/tolerability drive early discontinuation in China; ~30% of responders skip maintenance in elderly cohorts 6 | In China RWE, lenalidomide/bortezomib mitigate high-risk cytogenetic impact; thalidomide does not 24 |
| First relapse (1st salvage) | Any | Anti-CD38 triplets (e.g., Dara-Pd, DVd, DKd) or PI/IMiD-based triplets; consider CAR-T/bispecifics depending on prior exposure 2830 | Daratumumab-based triplets prevalent; carfilzomib/pomalidomide access improving; salvage ASCT when feasible 7810 | China anti-CD38 earlier-line use growing but still commonly 2L+; formulary and provincial reimbursement vary 71516171819 | Earlier anti-CD38 use associates with higher ORR in China registry data 7 |
| Later relapses (≥2L) | Any | BCMA CAR-T (ide-cel, cilta-cel) or BCMA bispecifics (teclistamab, elranatamab) widely available at qualified centers; selinexor and others as needed 1020 | BCMA CAR-Ts (cilta-cel; domestic products) exist but access limited to authorized centers/pilots; teclistamab listed as approved in dataset but real-world uptake not described 1011 | China: high out-of-pocket cost, limited center distribution, pilot reimbursement; U.S.: CMS coverage and broad center network 101120 | No China center counts or wait-time data found in retrieved materials; access remains the major limiter |
5) Clinical interpretation and planning implications
- Upfront intensity and transplant integration: U.S. practice has clearly shifted to anti-CD38–based quadruplets for both transplant-eligible and non-frail, transplant-ineligible patients, with strong PFS/MRD advantages and broad reimbursement support 1212132830. China’s formal recommendations align, but real-world adoption of quadruplets is tempered by cost, center capacity, and insurance heterogeneity—especially outside tier-1 cities. Planning in China often begins with VRd and escalates to anti-CD38 additions when feasible [CSCO 2025; citation:8].
- ASCT patterns: ASCT remains a key component in both regions; however, U.S. patients derive consistent benefit across subgroups and age strata in real-world data 4. In China, overall ASCT use is high in national datasets but falls significantly in older adults; practical referral constraints and age-based selection drive differences in who actually receives transplant 2931. Early stem cell collection after ≤4 cycles (especially if lenalidomide-containing induction) is emphasized in Chinese guidance to avoid mobilization issues and preserve later transplant options [2021 Chinese auto-HSCT guidance].
- Maintenance therapy: Lenalidomide maintenance after ASCT is a durable SOC in the U.S. and increasingly augmented by daratumumab in selected patients 1272830. In China, maintenance improves outcomes but is underutilized—about one-third of responders receive no maintenance in some elderly cohorts, and duration is often shorter than recommended due to cost/tolerability 624. Broader NRDL coverage and price reductions (e.g., for lenalidomide) are helping but have not eliminated adherence gaps 1516171819.
- Relapsed/refractory therapy: The U.S. can deploy anti-CD38 triplets and move rapidly to BCMA-targeted cellular or bispecific therapies with CMS coverage and established logistics 1020. China’s regulatory approvals now include multiple BCMA CAR-Ts (and teclistamab per dataset), but practical access remains limited to pilot zones and designated centers, with substantial out-of-pocket costs and referral complexities 10111516171819. Clinicians should prioritize clinical trial enrollment for high-risk disease and later relapses to bridge access gaps 8.
- Risk- and MRD-directed care: U.S. guidelines and PERSEUS support MRD-informed maintenance strategies and intensification in high-risk disease 12830. China’s 2024 high-risk consensus explicitly recommends CD38-based quadruplets and tandem ASCT for fit HRMM; maintenance should include two or three drugs until progression or intolerance 8. Routine FISH/MRD testing and geriatric assessment are important but variably available across Chinese centers; these infrastructure differences should be considered when tailoring therapy intensity and duration.
Caveats and data gaps
- The retrieved materials did not provide center-level counts, wait times, or bed/slot capacity for CAR-T delivery in either region; similarly, no hospital formulary inclusion rates for anti-CD38 agents in China were found.
- The Drug-Analysis dataset reflects a product inventory and may not fully align with current labels; its listings (e.g., teclistamab approval in China) should be cross-checked locally before use in clinical decision-making 10.
- Where Chinese CSCO guidance excerpts were available without numeric citations, they are presented as provided in the retrieved materials.
Overall, while the formal therapeutic playbooks are converging, the “how” and “when” of implementation still differ. In the U.S., quadruplet induction, routine ASCT for fit patients, and widespread access to maintenance and BCMA-targeted therapies underpin a consistent pathway across practice settings. In China, clinicians increasingly follow the same algorithm but must navigate provincial reimbursement, infusion capacity, transplant referral logistics, and heterogeneous access to CD38 antibodies and cellular therapies. For patient counseling and planning, these constraints should be made explicit, and trial enrollment pursued proactively in high-risk and relapsed disease.