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There are now more therapies for multiple myeloma than ever before, with new treatments under development in clinical trials. Hematologist-oncologists (specialists in both blood diseases and blood cancers) recommend treatments they think will be most effective based on the type of myeloma a person has, the stage of their myeloma, which treatments they’ve tried, and how their myeloma has responded to previous treatments.
Hematologist-oncologists also consider the person’s age, overall health, and any other conditions they may have. Ultimately, the treatment a person chooses should be based on a collaborative decision between them and their healthcare team.
In most cases, multiple myeloma is not curable. The majority of people with the condition experience a relapse (return of cancer) at some point. However, the effectiveness of new medications and treatment regimens means that, for many, multiple myeloma can be managed as a chronic condition. Some myeloma medications are so new that long-term data is not yet available. Despite this, survival rates for people with multiple myeloma continue to improve due to these advancements.
In the early stages of myeloma and related conditions, such as monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM), doctors typically recommend watchful waiting (observation) with periodic tests and examinations. This approach allows for close monitoring of the condition without starting treatment immediately.
If test results show myeloma is progressing or that a person starts to show symptoms, doctors may then recommend initiating treatment. In certain cases, when myeloma cells possess specific genetic characteristics that indicate a high risk of progression, doctors might advise those with SMM to begin treatment earlier than usual.
Most cases of myeloma are treated with a combination of therapies. Healthy lifestyle choices, such as maintaining a nutritious diet and engaging in regular exercise, can help those with myeloma feel their best and recover more effectively from treatment. The treatment options listed below are the most common ones for myeloma.
Chemotherapy involves the use of drugs to destroy cancer cells by stopping or slowing their growth. High-dose chemotherapy followed by autologous stem cell transplant — which uses cells harvested from the person’s own body — is a common treatment for some people when they’re first diagnosed with symptomatic multiple myeloma.
Certain chemotherapy drugs must be infused intravenously (by IV), while others are injected intramuscularly (into a muscle) or taken orally. Chemotherapy is often given in three different phases: induction therapy (also called “initial therapy”), consolidation therapy, and maintenance therapy. Different drugs or doses may be used during each phase.
There are many classes of chemotherapy drugs for myeloma. Most chemotherapy drugs used for myeloma are given in combinations of two or more. Chemotherapy medications may also be combined with other classes of drugs, including corticosteroids — such as dexamethasone and prednisone — or immunomodulatory drugs (see below).
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. Some chemotherapy drugs are approved by the U.S. Food and Drug Administration (FDA) to treat all cases of myeloma. Others are only approved to treat myeloma that is refractory (resistant to treatment) or relapsed (returned after being treated).
Common classes of chemotherapy drugs used for myeloma include:
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, including the drug combination your doctor prescribes, your dosage, and how well your body can tolerate the treatment. You may be able to manage some side effects with additional medication.
The most common side effects of chemotherapy include:
Some chemotherapy treatments also affect reproduction and fertility in many ways, both temporarily and permanently. 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.
Other medications used to treat myeloma include immunomodulatory drugs. These medications alter the way your immune system functions, enhancing its ability to fight cancer more effectively. Immunomodulators approved for use are thalidomide (Thalomid), lenalidomide (Revlimid), and pomalidomide (Pomalyst).
Lenalidomide is currently the standard of care used in maintenance for myeloma and is also used in combination with other drugs for as induction treatment. Studies have shown that lenalidomide can significantly improve progression-free survival (the time until a treated disease gets worse). Maintenance therapy begins after induction therapy (the initial treatment) and consolidation therapy (the next treatment) of high-dose chemotherapy with stem cell transplant.
In a study, maintenance therapy with lenalidomide sustained remission for at least 57 months in 50 percent of participants after a stem cell transplant, compared to 30 months without maintenance treatment. Lenalidomide is considered a well-tolerated drug, which is one reason it has become a standard of care for maintenance therapy. Side effects include an increased risk of changes in blood counts and a higher risk of blood clots.
Other immunomodulatory medications such as thalidomide, which has been used in maintenance therapy for myeloma, are now considered less advantageous because of toxicity and the risk of peripheral neuropathy (damage to nerves outside the brain and spinal cord).
Monoclonal antibodies are genetically engineered proteins that can kill cancer cells directly or aid the immune system in targeting and destroying cancer cells. Monoclonal antibodies approved to treat myeloma include:
Daratumumab is sometimes used for maintenance therapy in combination with lenalidomide.
Chimeric antigen receptor T-cell therapy (CAR T-cell therapy) modifies your T cells to enhance their ability to fight cancer.
During CAR T-cell therapy, oncology doctors remove a person’s T cells (a type of white blood cell). The T cells are genetically modified in a lab to “train” them to recognize a protein called B-cell maturation antigen (BCMA) found on the surface of myeloma cells. Once modified, the T cells are returned to the person with myeloma, where they begin attacking cancerous plasma cells.
Approved CAR T-cell treatments for myeloma include idecabtagene vicleucel (Abecma) and ciltacabtagene autoleucel (Carvykti). Both of these medications are available only after other treatments have failed or stopped working.
Bispecific T-cell engagers (BiTEs) are a newer approach to treating relapsed or refractory multiple myeloma that involves antibodies that can bind to two antigens at once. The FDA approved the BiTE teclistamab-cqyv (Tecvayli) in 2022 for treating people who had previously tried three prior lines of therapy.
BiTEs work by targeting BCMA and the CD3 protein found in T cells. As a result, teclistamab-cqyv causes tumor-cell lysis (destruction).
Other bispecific T-cell engagers sometimes used to treat myeloma are talquetamab-tgvs (Talvey) and elranatamab-bcmm (Elrexfio).
Targeted therapies limit how much cancer cells can divide, multiply, and spread. There are a number of these kinds of therapies for myeloma.
Proteasome inhibitors, such as carfilzomib (Kyprolis), ixazomib (Ninlaro), and bortezomib (Velcade), stop myeloma cells from destroying extra proteins. When too many proteins build up and the cell can’t remove them, the cell dies.
Mayo Clinic recommendations include using bortezomib for maintenance therapy in people with certain high-risk genetic abnormalities. Side effects for bortezomib include lowered blood counts, diarrhea, and fatigue. These drugs may also be recommended after relapses or if earlier treatments don’t work.
Another targeted therapy, selinexor (Xpovio), is in a new class of medications called “nuclear export inhibitors” that prevent cancer cells from properly transporting proteins.
Bisphosphonates, such as pamidronate (Aredia) and zoledronic acid (Zometa), can reduce the risk of complications related to bone lesions in some people with myeloma. Denosumab (Xgeva), a biologic drug, is often used to treat myeloma instead of bisphosphonates, particularly in those with reduced kidney function. It helps lower the risk of spinal fractures and spinal cord compression in people whose spines have been weakened by myeloma.
Radiation therapy (also called radiotherapy) is commonly used to treat solitary plasmacytoma — a single lesion in the bone or soft tissues. 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 lesions.
Radiation interferes with cell division. Since cancer cells divide much more rapidly than normal cells, they’re more vulnerable to radiation. Radiation kills cancer cells, while the normal, healthy cells of your body are better able to survive and heal.
Radiation schedules differ based on factors including the size, location, and type of tumor and what other treatments a person is receiving.
Most common side effects of external beam radiation to the bone are short term. These include:
These changes are usually gone within six to 12 months after radiation treatment ceases, but they 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 (plasma cell tumors located outside of the bones), or localized myeloma, your doctor may recommend surgical resection — cutting away the lesion or removing the tumor from the healthy bone or tissue.
In those whose myeloma has affected the pelvis or the spine, hip replacement or spinal surgery may relieve pain and restore the ability to walk.
Stem cell transplants, following high-dose chemotherapy, are a common treatment for people newly diagnosed with symptomatic multiple myeloma. The purpose of a stem cell transplant is to replace cancerous bone marrow cells with stem cells that will generate healthy bone marrow. Stem cell transplants occur after the cancerous cells of the bone marrow have been destroyed with chemotherapy.
In the past, cells for transplants were sourced from bone marrow, leading some people to still refer to stem cell transplants as “bone marrow transplants.” However, blood is now the most common source of stem cells for transplant in multiple myeloma cases.
There are two types of stem cell transplant: autologous and allogeneic. The majority of people with multiple myeloma receive an autologous stem cell transplant.
In an autologous stem cell transplant, stem cells are harvested from the person’s own body. Autologous transplants are preferable in most cases because the cells do not attack the body. However, the risk is that the harvested stem cells may be contaminated with myeloma cells, potentially contributing to a relapse. Autologous stem cell transplantation cannot cure myeloma.
Less commonly, an allogeneic stem cell transplant may be considered. In an allogeneic transplant, stem cells are harvested from a donor. 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.
Receiving a stem cell transplant is similar to undergoing a blood transfusion. Between 30 percent and 40 percent of people with myeloma undergo outpatient stem cell transplants, with daily monitoring for side effects. Most individuals, however, will be admitted to the hospital and can expect a two- to three-week stay during recovery.
You’ll need a variety of medications after a stem cell transplant, including antibiotics, antivirals, and antifungals. You may also get transfusions and take erythropoietin (EPO), a hormone that encourages and speeds the growth of red blood cells.
Short-term side effects of stem cell transplant can include:
After undergoing an autologous stem cell transplant, a person will receive several years of maintenance medications to sustain the treatment response. People who receive allogeneic stem cell transplants may need to take antirejection medication for life.
Some treatments aren’t prescribed to fight myeloma but to reduce symptoms of the condition and the side effects of treatments. Supportive care 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.
The most common supportive treatment plans for myeloma include:
For those who have had multiple relapses and exhausted their cancer treatment options, clinical trials may be a viable option. These studies test potential new treatments that aren’t yet FDA-approved for treating multiple myeloma but show promise. Clinical trials may also use new combinations of already-approved drugs that haven’t yet been tested together.
Numerous other drugs are in clinical trials for myeloma maintenance therapy. You can ask your healthcare providers if any of these studies to investigate potential treatments may be appropriate for you. As of July 2024, at least two drugs, iberdomide and megzidomide, are in clinical trials.
There are also promising trials underway for:
If you’re interested in learning more about clinical trials for relapsing multiple myeloma, talk to your hematologist-oncologist. They can recommend studies for which you may be eligible and discuss the benefits and risks of clinical trials.
No natural, alternative treatments have proved 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, and 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’s important to talk to your healthcare team before trying any.
Treatment of multiple myeloma 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:
MyMyelomaTeam is the social network for people with myeloma. On MyMyelomaTeam, more than 27,000 members come together to ask questions, give advice, and share their stories with others who understand life with myeloma.
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I just had mine in vancouver in June. It is an amazing process. I was given the melphalan chemo one day then my stem cells were given back the next day. I felt pretty crappy in a few days, everyone is… read more
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