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Weighing the Risks and Benefits of Myeloma Treatment Options

Posted on August 09, 2022
Medically reviewed by
Richard LoCicero, M.D.
Article written by
Caroline Wallace, Ph.D.

  • Every myeloma therapy option comes with potential benefits and potential risks.
  • Your doctor will help you understand which of the possible pros and cons apply to you, based on your stage of myeloma, your age, and your overall health, including any other conditions you have.
  • Ultimately, your chosen treatment is a personal decision based on your preferences, priorities, and treatment goals.

If you or a loved one has been diagnosed with multiple myeloma, you may feel overwhelmed by cancer treatment options. Although myeloma is generally not curable, the effectiveness of new treatments continues to increase survival.

Your hematologist-oncologist, or blood cancer specialist, will recommend a treatment regimen based on multiple factors. Details about your age, overall health, and stage of myeloma, as well as any other conditions you may have, all play a role in determining which treatment will work best for you. In shared decision-making, you and your doctor work together to choose a treatment plan based on your preferences, priorities, and goals. This article will help you weigh the risks and benefits of different myeloma treatment options to prepare you for an informed discussion with your doctor.

General Risks and Benefits of Cancer Treatment

Multiple myeloma is an uncommon type of blood cancer that affects plasma cells, a type of white blood cell that makes antibodies to help fight viruses. Myeloma causes a person’s plasma cells to grow abnormally and at a rapid, uncontrolled rate.

Cancer treatments are designed to stop or slow disease progression by killing cancer cells. Doctors prescribe treatments to give a person a better chance of living longer with as few cancer symptoms as possible.

Some treatments have serious side effects that sound scary but are very rare. Therapies also may have extremely positive potential benefits, but the results may be relatively short-lived. Your personal preferences are important to consider when choosing a treatment, including how you value extra time (months or years) versus side effects that may reduce your quality of life or independence, as well as the financial burden of the treatments.

Myeloma Treatment Risks and Benefits

There are numerous treatments for myeloma. Often your doctor will design a regimen that includes multiple therapies. The potential benefits and risks of each of the most common treatment options are reviewed below.

Myeloma treatment works best when taken exactly as directed. Read more about the importance of staying on myeloma treatment.

Alkylating Agents and Anthracyclines

Two types of chemotherapy, alkylating agents and anthracyclines, prevent the growth of cancer cells by inhibiting and damaging their DNA. The alkylating agents melphalan (Alkeran) and cyclophosphamide (Cytoxan) are commonly used to treat people with myeloma, as are the anthracyclines doxorubicin (Adriamycin) and liposomal doxorubicin (Doxil).

Because these drugs are generally very effective, they are often prescribed. However, as they work to destroy cancer cells, these medicines also can affect healthy cells in the body. This leads to the common chemotherapy toxicities, or side effects, including:

  • Nausea
  • Vomiting
  • Anemia (low red blood cell counts)
  • Low platelet counts (which can lead to abnormal bleeding)
  • Low white blood cell counts
  • Hair loss

These agents are also associated with cardiovascular disease or heart failure risk, which is why your doctor will carefully weigh the benefits of these medications against the potential risks. If you already have heart disease, your doctor may deem the risk higher.

Proteasome Inhibitors

Proteasome inhibitors interfere with cancer cells’ waste-removal systems. These medications prevent the cells from disposing of extra proteins, causing the cells to die. Carfilzomib (Kyprolis), ixazomib (Ninlaro), and bortezomib (Velcade) are proteasome inhibitors currently used for treating multiple myeloma.

This commonly prescribed type of myeloma treatment is partly responsible for improved survival and quality of life for people living with multiple myeloma. Some proteasome inhibitors can be taken orally rather than as an IV infusion.

Side effects associated with proteasome inhibitors include:

  • Fatigue
  • Low platelet counts
  • Anemia
  • Gastrointestinal upset
  • Headache
  • Fever

Some people also develop peripheral neuropathy — weakness or numbness in the hands and feet due to nerve damage. Drug resistance is also a challenge with proteasome inhibitors. People who initially had good responses to this therapy may stop seeing positive results after a while. Your doctor can help you understand how long the potential benefits might last for you.

Histone Deacetylase Inhibitors

Histone deacetylase (HDAC) inhibitors block the function of certain enzymes, interfering with cell division. The HDAC inhibitor panobinostat (Farydak) is usually combined with other medications for cases of refractory multiple myeloma — disease that has stopped responding to other drugs.

A late-stage study called PANORAMA 1 showed that panobinostat helped extend survival in people with myeloma. Potential side effects of panobinostat include:

  • Gastrointestinal upset
  • Severe diarrhea
  • Pneumonia
  • Infections
  • Heart rhythm changes

Monoclonal Antibodies

Monoclonal antibodies are a type of immunotherapy that has significantly improved treatment options for people living with myeloma. Antibodies are proteins made by immune cells to fight infections. Monoclonal antibodies are laboratory-made molecules designed to attack specific protein targets on the surface of myeloma cells. These medications trigger an immune response that helps kill the cancer cells. There are currently five FDA-approved monoclonal antibodies for the treatment of multiple myeloma, each with different side effects.

Daratumumab

Daratumumab (Darzalex) attaches to the CD38 protein on myeloma cells and is administered as an IV infusion. Rarely, it may cause a severe reaction that includes breathing trouble and dizziness. The most common side effects are:

  • Nausea
  • Back pain
  • Fever
  • Cough
  • Fatigue
  • Low blood cell counts

Daratumumab and Hyaluronidase-fihj

This form of daratumumab (Darzalex Faspro), which is combined with hyaluronidase-fihj, is given as an injection under the skin. The drug duo has the same risk of side effects as daratumumab alone.

Isatuximab-irfc

Isatuximab-irfc (Sarclisa) also attaches to the CD38 protein and is given as an IV infusion. In rare cases, it may cause severe reactions such as breathing problems or dizziness. Respiratory infections, diarrhea, and lower blood cell counts are more common side effects.

Elotuzumab

Elotuzumab (Empliciti) recognizes a different protein on the surface of myeloma cells, SLAMF7. A person may experience temporary fever, chills, dizziness, or trouble breathing soon after receiving the elotuzumab infusion. Common side effects include:

  • Loss of appetite
  • Diarrhea
  • Fever
  • Peripheral neuropathy
  • Upper respiratory tract infections

Belantamab Mafodotin

Belantamab mafodotin-blmf (Blenrep) is an antibody-drug conjugate — a monoclonal antibody is linked to a chemotherapy drug. Because of its severe side effects, this medication is given only after a person has already tried four other myeloma treatments. Severe fatigue, fever, nausea, and reactions during the infusion are common. Additionally, in rare cases, this drug can cause severe eye problems such as blurry or lost vision.

Radiation Therapy

Radiation therapy is an option for single lesions, called plasmacytomas, in the bone or soft tissues. Radiation can help prevent paralysis if a plasmacytoma presses on a nerve and can reduce cancer-associated bone pain.

The risks of radiation therapy include short-term side effects such as nausea, diarrhea, fatigue, and skin damage similar to a sunburn. These reactions usually subside within six months to a year after ending treatment. Nerve damage is a less common side effect. Angiosarcoma, a different type of cancer, is a very rare but serious side effect that can develop later.

Stem Cell Transplant

In a stem cell transplant, also called a bone marrow transplant, high-dose chemotherapy or radiation is given first to destroy the cancerous cells in the bone marrow. Then the person is given healthy stem cells to form new, healthy bone marrow. Autologous stem cell transplant uses a person’s own stem cells, previously removed from their blood. This treatment is a long process, involving many steps, but it can make myeloma go away for several years.

Another type of stem cell transplant, allogeneic transplant, involves blood-forming stem cells from a donor. This type of stem cell transplant may provide better anticancer results but has an increased risk of severe complications, such as graft-versus-host disease. Because of this risk, allogeneic transplants are not considered a standard treatment for people with myeloma.

Surgery

Surgery may be recommended in some myeloma cases when plasmacytomas form and cause extreme bone pain or press on spinal nerves. Surgery doesn’t slow the progression of myeloma — it just removes the plasmacytoma — but may rapidly improve quality of life if pain is reduced and function is restored.

Surgery brings the risks of excessive bleeding (hemorrhage), infection, pain, and reactions to the anesthesia. People with myeloma may have increased surgery risks, including in-hospital pneumonia, surgical site infection, and kidney failure.

Chimeric Antigen Receptor T-Cell Therapy

Chimeric antigen receptor (CAR) T-cell therapy harnesses a person’s immune system to fight their cancer. In 2021, the FDA approved idecabtagene vicleucel (Abecma) for the treatment of myeloma. The study that led to the approval showed that tumor burden (number of cancer cells, size of a tumor, or amount of cancer in the body) was completely or partially reduced in 72 percent of patients receiving CAR T-cell therapy, and 33 percent had a complete response to the treatment.

The most commonly reported side effects were low blood cell counts. CAR T-cell therapy can also lead to cytokine release syndrome — a usually mild but potentially severe reaction to proteins the body releases after immunotherapy — and nervous system problems.

Test your knowledge of multiple myeloma treatments with this quiz.

Speak With Your Doctor

Only your oncologist can help you understand your own potential benefits and risks from the different myeloma treatments. Although treatment choice is a very personal process, your doctor’s partnership will help you make the most informed decision. Prepare for a discussion with your doctor by writing down all your questions. Many people find it helpful to bring a trusted family member or friend to help them remember the discussion and ask any questions that may be accidentally overlooked.

Get help with preparing to talk to your doctor about multiple myeloma treatments.

Talk With Others Who Understand

On MyMyelomaTeam, the social network for people with multiple myeloma and their loved ones, more than 16,000 members come together to ask questions, give advice, and share their stories with others who understand life with myeloma.

How have you weighed the benefits and risks of different myeloma treatment options? Did your health care provider help you balance the pros and cons of each type of therapy? Share your experience in the comments below, or start a conversation by posting on your Activities page.

References
  1. Multiple Myeloma Drugs and Therapy — Memorial Sloan Kettering Cancer Center
  2. Plasma Cell — National Cancer Institute
  3. Status Update: Shared Decision-Making in Hematology — ASH Clinical News
  4. Cancer Treatment — Mayo Clinic
  5. Quality of Life Versus Length of Life Considerations in Cancer Patients: A Systematic Literature Review — Psycho-Oncology
  6. How Chemotherapy Drugs Work — American Cancer Society
  7. Cardiovascular Adverse Events in Modern Myeloma Therapy — Incidence and Risks. A Review From the European Myeloma Network (EMN) and Italian Society of Arterial Hypertension (SIAA) — Haematologica
  8. Proteasome Inhibitors — Multiple Myeloma Research Foundation
  9. Next-Generation Proteasome Inhibitors for Cancer Therapy — Translational Research
  10. Overall Survival of Patients With Relapsed Multiple Myeloma Treated With Panobinostat or Placebo Plus Bortezomib and Dexamethasone (the PANORAMA 1 Trial): A Randomized, Placebo-Controlled, Phase 3 Trial — Lancet Haematology
  11. Panobinostat (Oral Route) — Mayo Clinic
  12. Monoclonal Antibodies for Myeloma: Make It Easy! — Journal of Oncology Practice
  13. Plasmacytoma — National Cancer Institute
  14. Angiosarcoma — National Cancer Institute Center for Cancer Research
  15. Stem Cell Transplant for Multiple Myeloma — American Cancer Society
  16. Graft vs Host Disease: An Overview In Bone Marrow Transplant — Cleveland Clinic
  17. Multiple Myeloma Surgery — Moffitt Cancer Center
  18. Patients With Multiple Myeloma Have More Complications After Surgical Treatment of Hip Fracture — Geriatric Orthopaedic Surgery & Rehabilitation
  19. FDA Approves BCMA-Targeted CAR T-Cell Therapy for Multiple Myeloma — National Cancer Institute
  20. Idecabtagene Vicleucel in Relapsed and Refractory Multiple Myeloma — The New England Journal of Medicine
  21. Cytokine Release Syndrome — National Cancer Institute
All updates must be accompanied by text or a picture.
Richard LoCicero, M.D. has a private practice specializing in hematology and medical oncology at the Longstreet Clinic Cancer Center, in Gainesville, Georgia. Review provided by VeriMed Healthcare Network. Learn more about him here.
Caroline Wallace, Ph.D. has a doctorate in biomedical science from the Medical University of South Carolina. Learn more about her here.

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