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There are now more treatments for myeloma than ever before, with new therapies under development in clinical trials. Hematologists-oncologists (blood disease and cancer specialists) recommend treatments they think will be most effective based on the type and stage of myeloma, what treatments have already been tried, and how your myeloma responded to previous treatments. Oncologists also take into account your age, overall health, and any other conditions you have. Ultimately, the choice of your myeloma treatment is up to you.
In most cases, multiple myeloma is not curable. The majority of people with multiple myeloma experience a relapse at some point. The effectiveness of new medications and regimens means that, for many people, myeloma is a chronic condition that can be managed with treatment. Some myeloma medications are so new that long-term data is not yet available. However, survival rates for people with multiple myeloma continue to improve.
In the early stages of myeloma and related conditions, such as monoclonal gammopathy of undetermined significance (MGUS) and smoldering myeloma, doctors typically recommend watchful waiting with periodic tests and examinations. If test results show myeloma is progressing, doctors may then recommend beginning treatment. In some cases, when myeloma cells are found to have specific genetic characteristics that carry a high risk for progression, doctors may recommend those with smoldering myeloma begin treatment sooner.
Myeloma treatments fall into five main categories: chemotherapy and other antimyeloma medications, radiation therapy, stem cell transplants, surgeries, and supportive treatments. Most cases of myeloma are treated with a combination of treatments. Healthy lifestyle choices, such as a nutritious diet and regular exercise, can help those with myeloma feel their best and recover from treatment more readily. Read details about specific treatments in Myeloma Treatments A-Z.
Chemotherapy is the treatment of cancer with drugs that destroy or slow the growth of cancer cells. High-dose chemotherapy followed by autologous stem cell transplant is a common treatment for people when they are first diagnosed with multiple myeloma. Certain chemotherapy drugs must be infused intravenously (by IV), while others are injected or taken orally. Chemotherapy is usually prescribed by a medical oncologist — a doctor who specializes in treating cancer with medications. Some doctors may refer to all medication prescribed for someone with myeloma as chemotherapy.
There are many classes of chemotherapy drugs for myeloma. Most chemotherapy drugs used for myeloma are given in combinations of two or more drugs. The regimen depends on the type of myeloma you have, the stage of your myeloma, whether you have tried other therapies before, and whether or not you are going to receive a stem cell transplant. Since many chemotherapy regimens for multiple myeloma involve three drugs, they are commonly referred to as “triplets.” If your myeloma progresses, or if you experience significant side effects, your medical oncologist may adjust your dosage or change the combination of drugs you receive.
Classes of chemotherapy drugs used for myeloma include alkylating agents, anthracyclines, and proteasome inhibitors. Alkylating agents, such as Alkeran (Melphalan), Cytoxan (Cyclophosphamide), and Treanda (Bendamustine), are believed to prevent the growth of cancer cells by inhibiting and damaging their DNA. Anthracyclines, including Adriamycin (Doxorubicin) and Doxil (Liposomal doxorubicin), slow the growth of cancer cells by interfering with cell division. Normal cells have the ability to self-destruct if they become cancerous. In cancer cells, this function is turned off, allowing abnormal cells to keep growing and replicating. Proteasome inhibitors, such as Kyprolis (Carfilzomib), Ninlaro (Ixazomib), and Velcade (Bortezomib), are believed to work by activating this self-destruct function in cancer cells.
Chemotherapy medications may be combined with other classes of drugs including corticosteroids such as Dexamethasone and Prednisolone or immunomodulators like Thalomid (Thalidomide), Revlimid (Lenalidomide), and Pomalyst (Pomalidomide). These drugs may enhance the effects of chemotherapy or reduce side effects.
Biologics, such as Darzalex (Daratumumab) and Empliciti (Elotuzumab), are genetically engineered proteins that can kill cancer cells directly or aid the immune system in targeting and destroying cancer cells.
If you are taking chemotherapy drugs orally, you can do so at home. If you are taking chemotherapy drugs intravenously, you will usually need to receive them in a clinical setting like a doctor’s office or cancer treatment center. You may receive them through a slow-drip IV infusion in your hand or arm, or as an intramuscular (into the muscle) or subcutaneous (under the skin) injection. You may also have a line or a port — a small, flexible tube — implanted temporarily beneath the skin to allow for chemotherapy access.
A course of chemotherapy is administered in cycles of treatment and recovery. Most people with myeloma will receive between four and 12 cycles of chemotherapy in one complete course. A course of chemotherapy usually lasts four to six months. During treatment, chemotherapy is administered for several hours over consecutive days. Each period of treatment will be followed by a recovery period of a few weeks to allow your body to rest. Your medical oncologist will determine your chemotherapy schedule based on many factors, including the type and stage of your myeloma, how well your cancer responds to treatment, and the severity of the side effects you experience.
Each class of chemotherapy drugs causes different side effects, some of which are very serious. What side effects you experience will depend on many factors: the drug combination your doctor prescribes, your dosage, and how well your body can tolerate the treatment. If you cannot tolerate the side effects, your doctor may try decreasing dosage or changing the combination in an effort to minimize danger and discomfort. Always report side effects to your doctor. Some side effects, such as nausea, can be eased with other medications.
Some of the most common side effects of chemotherapy include fatigue, nausea, vomiting, diarrhea, loss of appetite, weight loss, hair loss, skin problems, and mouth sores. Damage to bone marrow often results in a weakened immune system due to low white blood cell counts. Some chemotherapy drugs can cause neuropathy, or nerve damage. This may result in pain, tingling, or numbness in the extremities. These symptoms may be temporary or permanent.
Some people report cognitive side effects from chemotherapy, such as memory problems and trouble focusing or planning. These cognitive issues are sometimes referred to as “chemo brain.” These side effects usually disappear soon after the end of treatment, although fatigue may last for years after treatment is over.
Chemotherapy treatment also affects male and female reproduction in many ways, both temporary and permanent. Other serious late-term side effects of chemotherapy for myeloma can include damage to the heart and lungs, early menopause, and a higher risk for developing other cancers.
Stem cell transplant after high-dose chemotherapy is a common treatment for people when they are first diagnosed with multiple myeloma. The purpose of a stem cell transplant in multiple myeloma is to replace cancerous bone marrow cells with stem cells that will form healthy bone marrow. Stem cell transplants take place after the cancerous cells of the bone marrow have been destroyed with chemotherapy, radiation, or a combination of the two.
In the past, cells for transplant were taken from bone marrow. For this reason, some people still refer to stem cell transplants as bone marrow transplants. However, blood is now the most common source for stem cells for transplant in cases of multiple myeloma.
There are two types of stem cell transplant: autologous stem cell transplant and allogeneic stem cell transplant. The majority of people with multiple myeloma receive an autologous stem cell transplant. In an autologous stem cell transplant (ASCT), stem cells are harvested from the person’s own body. Autologous transplants are preferable in most cases because the cells will not attack the body. The risk with ASCTs is that the peripheral blood stem cells may be contaminated with myeloma cells, which may contribute to a later relapse. Autologous stem cell transplants cannot cure myeloma.
For those who will receive ASCTs, peripheral blood stem cells are harvested before chemotherapy or early in the cycle of chemotherapy. The cells are then frozen until they are needed for the transplant.
Less commonly, an allogeneic stem cell transplant may be considered. In an allogeneic transplant (allo-SCT), stem cells are harvested from a donor. This is usually a sibling or close blood relative, but sometimes it’s an unrelated person who is a good genetic match. Allogeneic transplants can cure myeloma in some cases, but they carry a high risk of severe side effects and death. Ideally, allogeneic stem cell transplants will trigger a process known as graft-versus-tumor or graft-versus-myeloma effect in which the transplanted cells help attack the cancer cells and potentially cure myeloma. However, the greater risk of graft-versus-host disease (GVHD) often outweighs this potential benefit of allogeneic stem cell transplant. In GVHD, the transplanted donor cells attack the host’s tissues. The effects of GVHD can range from mild, chronic symptoms to life-threatening emergencies.
The process of receiving a stem cell transplant is similar to receiving a blood transfusion. Stem cell transplants for multiple myeloma may be administered on an outpatient or inpatient basis. Between 30 percent and 40 percent of people with myeloma undergo outpatient stem cell transplants, with daily monitoring for side effects. The majority of people will be admitted to the hospital during the stem cell transplant process. Those admitted to the hospital for stem cell transplant can expect to stay two to three weeks during recovery.
During the first weeks of recovery from stem cell transplant, people with myeloma may receive antibiotics and antiviral or antifungal medications to protect against infection. They may also require transfusions of red blood cells or platelets (cell fragments involved in the clotting process) to replace those destroyed by chemotherapy. Those who have undergone stem cell transplant for multiple myeloma are often given Erythropoietin (EPO), a hormone that encourages and speeds the growth of blood cells.
Short-term side effects of stem cell transplant can include fatigue, headaches, fever and chills, nausea, vomiting, diarrhea, loss of appetite, weight loss, trouble sleeping, and skin rashes. Some people develop mucositis, an inflammation of the digestive tract that can cause pain and make it difficult to eat. Some side effects, such as nausea, can be eased with other medications. Fatigue may be longer-lasting, persisting beyond the immediate recovery period. It may take months to fully recover after receiving a stem cell transplant.
After receiving an autologous stem cell transplant, people with multiple myeloma will receive two to three years of maintenance medications to sustain the treatment response. People who receive allogeneic stem cell transplants may need to take antirejection medication for life.
Radiation therapy (also called radiotherapy) is commonly used to treat solitary plasmacytoma — a stage in the development of multiple myeloma involving a single lesion in the bone or soft tissues. Radiotherapy may be used as the only treatment for plasmacytoma, or it may be given during or after surgery to remove lesions. Radiation therapy may also be used to treat multiple myeloma in cases where chemotherapy has been ineffective at reducing pain in a limited number of bone sites. Radiotherapy is overseen by a radiation oncologist.
Radiation interferes with cell division. Since cancer cells divide much more rapidly than normal cells, they are more vulnerable to radiation. Radiation kills cancer cells, while the normal, healthy cells of your body are better able to survive and heal. Radiation therapy can help shrink tumor size, slow or prevent the spread of tumors, and may strengthen the bone and help treat pain.
Radiation schedules differ based on the size, location, and type of tumor; other treatments you are receiving; and additional factors. Radiation therapy is usually delivered five days a week during the treatment period, which is most commonly about four weeks — although it can last between two and 10 weeks. Receiving the treatment takes about 30 minutes, but it may take longer to prepare for the procedure.
Most common side effects of external beam radiation are short-term. These include fatigue, swelling, nausea, diarrhea, and skin damage similar to sunburn. These changes are usually gone within six to 12 months after radiation treatment ceases, but may linger for as long as two years. Less common side effects include nerve damage that can leave parts of the body feeling painful, weak, or numb. A very rare but serious side effect of external beam radiation can include developing a different type of cancer called angiosarcoma.
In some cases of solitary plasmacytoma, extramedullary myeloma, or localized myeloma, your doctor may recommend surgical resection — cutting away the lesion or removing the tumor from the healthy bone or tissue.
Some treatments are not prescribed to fight myeloma, but to reduce symptoms of myeloma and the side effects of myeloma treatments. Supportive treatments can include medications and medical procedures. The goal of supportive treatments is to improve functionality and quality of life, and to reduce the severity of side effects.
Pain is a common symptom of myeloma and a side effect of many myeloma treatments. Opioids, such as Astramorph (Morphine), Codeine, Norco (Hydrocodone/Acetaminophen), Percocet (Oxycodone), and Ultram (Tramadol), may be prescribed to treat pain. Opioids are believed to work by reducing the perception of pain.
Anticonvulsants, such as Neurontin (Gabapentin) and Lyrica (Pregabalin), or antidepressants, including Cymbalta (Duloxetine), Elavil (Amitriptyline), and Norpramin (Desipramine), may be used to treat neuropathy (nerve pain) caused by chemotherapy. Anticonvulsants reduce pain signals sent by damaged nerves. Antidepressants are believed to work by changing the balance of neurotransmitters (chemicals that transmit messages) in the brain. Most people with myeloma should avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs), such as Ibuprofen or Naproxen, because drugs in this class can negatively affect the kidneys.
Medical marijuana may be prescribed to treat pain, nausea, vomiting, loss of appetite, and insomnia in people with multiple myeloma.
Bisphosphonates, such as Aredia (Pamidronate) and Zometa (Zoledronic acid), can reduce the risk of complications related to bone lesions in some people with myeloma. Xgeva (Denosumab) is a biologic drug that helps reduce the risk of spinal fractures and spinal cord compression in people whose spines have been weakened by myeloma.
Flu and pneumonia vaccines are recommended for people with myeloma and those who spend time with them. The immune systems of those with myeloma are compromised, and annual vaccines can help protect them from infection.
People with myeloma who develop anemia — low levels of red blood cells — may be given a blood transfusion or Erythropoietin (EPO). EPO is a hormone that stimulates red blood cell production in the bone marrow.
Many people with myeloma develop low levels of immunoglobulins — also known as Ig or antibodies — that recognize and destroy specific viruses and other threats. If antibody levels become too low, doctors sometimes recommend intravenous immunoglobulin (IVIG) to bolster the immune system and help protect against infection. IVIG is produced by pooling antibodies from thousands of blood donors. IVIG is administered by intravenous infusion (IV) in a medical setting. IVIG treatment is commonly given once a month while antibody levels are low.
In some cases of myeloma, cancer cells secrete large amounts of abnormal, ineffective antibodies, leading to the development of complications like amyloidosis or light chain deposition disease. These conditions can damage the kidneys and interfere with blood flow.
Plasmapheresis is a short-term treatment for acute kidney damage in people with myeloma. Plasmapheresis involves replacing the plasma, or liquid part of your blood, with either saline solution (a salt and water mixture) or plasma from a donor. The plasma and abnormal antibodies are removed, and your red and white blood cells are combined with the replacement plasma and returned to your body. Plasma exchange works by reducing the amount of abnormal immunoglobulins in the blood.
In about 10 percent of people with multiple myeloma, abnormal proteins cause kidney damage severe enough to require kidney replacement therapy. Dialysis is the most common type of kidney replacement therapy. There are two main types of dialysis, hemodialysis and peritoneal dialysis. Both types of dialysis provide a means of filtering waste products from the blood, taking over the role from the failing kidneys.
No natural, alternative treatments have been proven effective in clinical studies to treat myeloma. However, many people have found various complementary or alternative therapies effective for managing myeloma symptoms and side effects of myeloma treatment, such as pain, fatigue, nausea, anxiety, and depression. Some people have reported feeling better after therapies such as acupuncture, acupressure, or aromatherapy. Dietary supplements (including L-glutamine, the Japanese herb goshajinkigan, or omega-3 fatty acids) may also have a beneficial effect. However, since some natural or complementary treatments can interfere with myeloma medications or cause their own side effects, it is important to talk to your doctor before trying any alternative treatments.
Myeloma treatments can be very expensive. Some manufacturers of antimyeloma medications offer copay assistance programs for people with health insurance who have trouble affording their copay. Some people with low income and no health insurance qualify for programs that provide free medication. Several nonprofit foundations offer guides to help find assistance paying for myeloma medications. Visit the links below for more information:
Todd Gersten, M.D., is a hematologist-oncologist at the Florida Cancer Specialists & Research Institute in Wellington, Florida. Learn more about him here. Review provided by VeriMed Healthcare Network.