Multiple Myeloma

Treatment

You and your family have many decisions to make about your multiple myeloma treatment. This may be overwhelming, but your medical team will work with you to determine the best treatment plan. Doing research and talking to your doctor about treatment options, including your treatment goals and the side effects associated with treatment, are important.

Getting a second opinion is common, particularly when dealing with a complex health condition such as multiple myeloma. Different specialists offer various levels of expertise and experience, and each may favor a different approach. Ask plenty of questions to ensure that you understand your options, and take time to consider them.

Treatment options for multiple myeloma differ from person to person. Factors that will guide your treatment include the stage of the disease as well as your age, overall health and symptoms. Your doctor may recommend one or a combination of the following therapies.

Watchful Waiting

Waiting to start treatment until after symptoms begin is called watchful waiting. People with monoclonal gammopathy of unknown significance (MGUS), smoldering myeloma or early-stage disease who do not have symptoms generally do not need immediate treatment. Monitoring these conditions and waiting to begin treatment offers people the possibility of avoiding the side effects of treatment as long as possible and, hopefully, without affecting their outcome.

During watchful waiting, people should have regular checkups to look for signs and symptoms. These appointments are important because treatment should begin as soon as the disease progresses or symptoms appear.

Bisphosphonates

The collection of myeloma cells in the bone marrow can lead to bone lesions and the destruction of bone. Bisphosphonates are drugs that can treat bone problems caused by multiple myeloma and prevent further bone damage from occurring.

People with smoldering myeloma who have bone loss may take bisphosphonates during a period of watchful waiting, and people with multiple myeloma may take them as part of their treatment.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells by preventing them from growing and dividing. This form of treatment is known as systemic therapy, meaning the drugs travel through the bloodstream and affect cells throughout the entire body. Chemotherapy drugs work by attacking cancer cells that grow and multiply quickly, occasionally causing damage to healthy cells that also grow and multiply rapidly.

Most people with multiple myeloma receive some form of chemotherapy, which may consist of a single drug or multiple drugs given in combination. It may also be combined with other types of treatments. Chemotherapy is usually given in cycles that consist of a treatment period followed by a break to allow the healthy cells to recover.

Chemotherapy may be injected intravenously (into a vein via a needle or catheter, which is a thin, flexible tube) or given orally in the form of a pill. Many oral drugs may be taken at home (see Medication Adherence), and intravenous (IV) drugs may be given in a doctor’s office, clinic or hospital (see Figure 1).

                                            Figure 1.

Targeted Therapy

Like chemotherapy, targeted therapy is considered a systemic treatment because the drugs travel throughout the body via the bloodstream. Targeted therapy drugs seek out specific genes, proteins and tissue environments of myeloma cells to block the growth and spread of cancer. These drug therapies help your medical team control the disease and generally have different side effects than traditional chemotherapy.

Three types of targeted therapy drugs used to treat multiple myeloma are proteasome inhibitors, histone deacetylase (HDAC) inhibitors and angiogenesis inhibitors. Proteasome inhibitors target enzymes in what are termed proteasomes that digest proteins in cells, helping to slow or stop myeloma cell growth and development. HDAC inhibitors interact with histones (proteins in chromosomes) to affect the gene expression inside myeloma cells. Angiogenesis inhibitors work by blocking the growth of new blood vessels that feed myeloma cells.

Immunotherapy

Immunotherapy is a treatment that works with or stimulates a person’s own immune system to recognize and destroy cancer cells (see Figure 2). This approach may result in fewer side effects. Because myeloma cells are developed from mutated healthy cells in the body, the immune system may have difficulty recognizing myeloma cells as foreign. Training the immune system to respond to cancer has the potential for a more lasting response that can extend beyond the end of treatment.

Immunomodulating agents are a type of immunotherapy drug used to treat multiple myeloma. These drugs can be effective in treating newly diagnosed multiple myeloma and relapsed or refractory disease.

Monoclonal antibodies are another type of immunotherapy drug used to treat multiple myeloma. Antibodies (proteins) are made by the immune system to help fight infection. Monoclonal antibodies are designed to attack a specific target, such as proteins found on myeloma cells.

                  Figure 2.

Stem Cell Transplantation

Stem cell transplantation (also known as bone marrow transplantation) is an infusion of healthy stem cells into the body. The healthy cells can be collected from blood, bone marrow or umbilical cord blood from the patient, a family member or another donor.

There are two main types of stem cell transplantation. Autologous stem cell transplantation uses stem cells that come from your own body and is the most common type of transplant used to treat multiple myeloma. During this procedure, stem cells are collected (harvested) and frozen. High-dose chemotherapy is then given. Once chemotherapy is complete, the harvested stem cells are thawed and given back to the patient through a catheter in a large vein, similar to how a blood transfusion is given. These healthy stem cells help regenerate healthy, new blood cells in the bone marrow.

Another type of stem cell transplantation is allogeneic stem cell transplantation. With this type of transplant, the stem cells come from a volunteer donor whose tissue type closely matches that of the patient. If available, a sister or brother could be a close match because siblings share similar genes. If a sibling or another family member is not a good match, an unrelated volunteer donor may be found through a national registry (see “Lifesaving Donations” blue box below).

Although autologous transplantation is used to treat multiple myeloma more often, allogeneic transplantation may be used for patients with a high risk of relapse, those who aren’t responding fully to other treatments or those who have relapsed disease.

 


Lifesaving Donations


Stem cell transplantation is a common treatment option for some people with blood cancers or blood diseases. About 30 percent of people who need a bone marrow transplant have a family member who can donate to them. The other 70 percent do not have a matched donor in their family, which means they need an unrelated donor. To help people find donors, organizations, such as the National Marrow Donor Program, have created registries of millions of potential donors. Marrow and stem cell donations can be collected from blood through a peripheral blood stem cell (PBSC) donation, bone marrow or umbilical cord blood.

A donor registry, Be the Match, is operated by the National Marrow Donor Program. For more information, visit https://bethematch.org.

 

 

Radiation Therapy

Radiation therapy is a treatment that uses high doses of radiation to destroy cancer cells and shrink tumors. Some people with localized myeloma or bone pain that does not lessen with chemotherapy may receive radiation therapy to specific parts of the body. The most commonly used type is external-beam radiation therapy, in which radiation is directed at the cancer cells from an external source (a machine outside the body) (see Figure 3).

                                            Figure 3.

Corticosteroids

Corticosteroids are myeloma cell-fighting drugs that are used to treat multiple myeloma and ease the side effects of chemotherapy, particularly nausea and vomiting. These drugs can be used alone or in combination with chemotherapy. They are given in either oral or injection form.

Surgery

Surgery may be used to treat a single plasmacytoma (malignant plasma cell tumor), but it is rarely used to treat multiple myeloma. In cases of weakened bone, metal plates or rods may be placed to provide support or to prevent fractures.

Clinical Trials

Clinical trials are the controlled studies of investigational drugs. The main goal of clinical trials is to confirm a drug’s safety and effectiveness, but they also help determine a variety of other factors, including the drug’s associated side effects and recommended dosages (see Clinical Trials). Ask your doctor or a member of your health care team about clinical trials.

Common Drug Options

Treatment type Commonly used drugs
Bisphosphonates
  • pamidronate (Aredia)
  • zoledronic acid (Zometa)
Chemotherapy
  • bendamustine (Treanda)
  • carmustine (BiCNU)
  • cyclophosphamide
  • doxorubicin (Adriamycin)
  • etoposide (Etopophos)
  • liposomal doxorubicin (Doxil)
  • melphalan (Alkeran)
  • vincristine (Oncovin)
Corticosteroids
  • dexamethasone
  • prednisone
Immunotherapy
            Antibodies
  • daratumumab (Darzalex)
  • elotuzumab (Empliciti)
            Immunomodulators
  • lenalidomide (Revlimid)
  • pomalidomide (Pomalyst)
  • thalidomide (Thalomid)
Targeted Therapy
  • bortezomib (Velcade)
  • carfilzomib (Kyprolis)
  • ixazomib (Ninlaro)
  • panobinostat (Farydak)

Additional Resources

 

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