Multiple Myeloma

Treatment

Treatment of multiple myeloma begins when patients start to experience symptoms. But for those who do not yet have symptoms, doctors may closely monitor patients diagnosed with MGUS or early-stage myeloma with an approach known as active surveillance or watchful waiting. Studies have shown that starting therapy in individuals with no symptoms does not improve their chances of long-term survival any more than active surveillance and avoids the side effects associated with treatment.

The goals of treatment, once symptoms emerge, are to reduce the numbers of myeloma cells in the body, eliminate such symptoms as bone pain or fatigue and provide disease remission (periods when people no longer have any signs or symptoms of the disease). The treatment an individual receives depends on the stage of the disease and the individual’s symptoms, age and overall health.

Treatment Options

The treatment options for multiple myeloma include chemotherapy, stem-cell transplantation, radiation therapy and supportive therapies to relieve such symptoms as infections or bone damage. Treatment plans for this disease most often recommend combinations of therapies.

Chemotherapy. The mainstay treatment for multiple myeloma is chemotherapy, that is, the use of drugs to kill myeloma cells. Chemotherapy helps some patients achieve sustained disease remissions or significant slowing of disease progression. Side effects depend on the overall health of the individual and the dose of drug used but can include infections, fatigue, loss of appetite, nausea, vomitting, diarrhea and neuropathy (nerve damage). Treatment is usually given until the disease stops progressing or the patient has a remission. The side effects usually end when the treatment ends.

Greater knowledge of the biology of multiple myeloma has led to the development of new drugs that target not only myeloma cells but also specific genes and the environment of myeloma cells that contribute to cancer growth and spread. These new drug therapies have greatly improved the treatment of this disease by helping physicians achieve better control of the disease process.

Among the first targeted drugs developed were so-called angiogenesis inhibitors. Angiogenesis is the process by which the body produces new blood vessels. Angiogenesis inhibitors are thought to stop the growth of new blood vessels feeding the growth and spread of cancerous cells and tumors. The angiogenesis inhibitors currently available for the treatment of multiple myeloma are the oral medications (taken by mouth) thalidomide (Thalomid) and lenalidomide (Revlimid).

Lenalidomide (generally favored over thalidomide because of thalidomide's toxicity) may be used in combination with dexamethasone  to treat newly diagnosed multiple myeloma patients or those who have already been given at least one other drug treatment.

Another targeted drug therapy is the so-called proteasome inhibitor bortezomib (Velcade), which targets enzymes that digest proteins in cells, known as proteasomes. Bortezomib is given by injection to treat both newly diagnosed and previously treated people with multiple myeloma. It may be used together with lenalidomide to treat recurring multiple myeloma or in combination with lenalidomide and thalidomide to treat newly diagnosed patients. Several new targeted therapies are under development.

Stem cell transplantation. This medical procedure uses either the patient’s own stem cells or stem cells from a donor to replace diseased bone marrow. The cells can come from the bloodstream or bone marrow itself. As targeted drug therapies for multiple myeloma have advanced, stem cell transplantation if often done after a patient has a good response to chemotherapy. The goal of this therapy is to destroy myeloma cells throughout the body.

Autologous stem cell transplantation is the term for transplants of the patient’s own stem cells. This is the standard stem cell treatment for multiple myeloma. The stem cells are obtained when the patient is in disease remission, typically after receiving drug therapy. Allogeneic stem cell transplantation is the term for transplants from a donor whose tissue matches the patient’s, usually a sibling, but unrelated individuals can also serve as donors. Allogeneic transplants are usually done for patients at high risk of adverse outcomes or recurrent disease. These transplants are much more dangerous than the other type.

Radiation therapy. Doctors may recommend the use of external-beam radiation (radiation sent from a machine outside the body) to target and kill cancer tumors and cells when chemotherapy fails to resolve or control bone pain.

Supportive therapies. To help reduce the symptoms and complications resulting from multiple myeloma, doctors frequently recommend supportive therapies. To help prevent bone loss that occurs with bone lesions and reduce the pain and risk of fractures, patients may receive bisphosphonate drugs that inhibit bone breakdown.

To treat anemia, doctors may recommend erythropoietin, a hormone that protects red blood cells from dying. For infections, doctors may recommend immunoglobulin replacement therapy to boost the immune system. And for kidney dysfunction, doctors may recommend drinking increased amounts of water or other fluids to flush out the kidneys, improve their ability to filter impurities from the blood and avoid kidney failure.