Multiple myeloma - Treatment

Treatment-Multiple myeloma




Treatment for multiple myeloma can often help to control symptoms and improve quality of life. However, myeloma usually can't be cured. This means additional treatment is needed when the cancer comes back (a relapse).
Not everyone diagnosed with myeloma needs immediate treatment – for example, the condition may not be causing any problems. This is sometimes referred to as asymptomatic or smouldering myeloma.
If you don't need treatment, you'll be monitored for signs the cancer is beginning to cause problems. If you do need treatment, the most commonly used options are outlined below.

Discussing your multiple myeloma treatment

If you have multiple myeloma, you'll be cared for by a team, which is usually led by a consultant haematologist who specialises in myeloma.
The team will discuss your condition and recommend the best treatment for you. However, the final decision to begin treatment will be yours.
Before visiting hospital to discuss your treatment options, it may be useful to write a list of questions to ask the specialist. For example, you may want to find out the advantages and disadvantages of a particular treatment.

Bringing myeloma under control

The initial treatment for multiple myeloma may be either:
  • non-intensive – for older or less fit patients (this is more common)
  • intensive – for younger or fitter patients
Both non-intensive and intensive treatments involve taking a combination of anti-myeloma medicines. But intensive treatment involves higher doses and is followed by a stem cell transplant.
The medicines usually include a chemotherapy medicine, a steroid medicine, and either thalidomide or bortezomib.

Chemotherapy

Chemotherapy medicines kill the myeloma cells. A number of treatments are often combined to treat multiple myeloma.
These treatments are often taken in tablet form. Side effects are usually mild but may include:
  • increased risk of infections
  • feeling sick
  • vomiting
  • hair loss
  • damage to nerves (neuropathy)
Your clinician will give you advice and information about your risk of developing potentially serious infections. They'll also tell you what you can do to reduce your risk.

Steroids

Corticosteroids help destroy myeloma cells and make chemotherapy more effective. The most common types used to treat myeloma are dexamethasone and prednisolone.
Steroids are taken by mouth after eating. Possible side effects include:

Thalidomide

Thalidomide can help kill myeloma cells. You take it as a tablet every day – usually in the evening, as it can make you feel sleepy.
Other common side effects include:
Thalidomide can cause birth defects, so should not be taken by pregnant women, and a reliable form of contraception such as a condom must be used during treatment.
There is also a risk you may develop a blood clot when taking thalidomide, so you may be given medication to help prevent this.
Contact your care team immediately if you develop symptoms of a blood clot, such as pain or swelling in one of your legs, or chest painand breathlessness.
Myeloma UK has more information on thalidomide.

Bortezomib

Bortezomib (Velcade) can help kill myeloma cells by causing protein to build up inside them.
There are some limitations as to who can have bortezomib, but a member of your care team will discuss this with you.
The medication is given by injection, usually under the skin. Possible side effects include:
Myeloma UK has more information on bortezomib.

Stem cell transplant

People receiving intensive treatment are given a much higher dose of chemotherapy medication as an inpatient to help destroy a larger number of myeloma cells. This aims to achieve a longer period of remission (where there is no sign of active disease in your body) but does not result in a cure.
However, these high doses also affect healthy bone marrow, so a stem cell transplant will be needed to allow your bone marrow to recover.
In most cases, the stem cells will be collected from you before you are admitted for the high-dose treatment. In very rare cases, they are collected from a sibling or unrelated donor.

Treating relapses

Further treatment is needed if myeloma returns. Treatment for relapses is similar to initial treatment, although non-intensive treatment is often preferred. A small group of people may benefit from a second course of high-dose treatment, which your haematologist would discuss with you.
Additional medicines – such as lenalidomide, pomalidomide, carfilzomib and daratumumab – and other chemotherapy medicines may also be given.
You may also be asked if you want to participate in clinical trial research into new treatments for multiple myeloma.

Lenalidomide and pomalidomide

Lenalidomide and pomalidomide are similar to thalidomide. They're both taken by mouth and can affect the cells produced by your bone marrow, which can cause:
  • increased risk of infection – as a result of a low number of white blood cells
  • anaemia – caused by a low number of red blood cells
  • bruising and bleeding – because of a low platelet count
They may also increase your risk of developing a blood clot and have other side effects similar to thalidomide.
Let your care team know if you experience any problems or unusual symptoms while taking lenalidomide or pomalidomide.
Myeloma UK has more information on lenalidomide and pomalidomide.

Carfilzomib

Carfilzomib is a medication similar to bortezomib. However, unlike bortezomib, it's given on a regular basis as a long-term treatment. It's also given as an injection into the veins (intravenous) rather than under the skin (subcutaneous).
Carfilzomib is a more intensive treatment than bortezomib, and your haematologist will give you advice about which treatment is best for you. Possible side effects include kidney and heart problems and, less commonly, nerve damage.
Myeloma UK has more information on carfilzomib.

Daratumumab

Daratumumab is a new antibody treatment available in the UK for treating myeloma when it has come back a number of times. It targets one of the proteins on myeloma cells called CD38 and helps kill the cancerous myeloma cells.
Daratumumab is given as an intravenous drip on a long-term, regular basis.
Your haematologist will discuss the possible side effects with you, but most people tolerate it very well. However, the first dose often causes an allergic reaction, which will mean an overnight stay in hospital.
Myeloma UK has more information on daratumumab.

Panobinostat

Panobinostat is a newer treatment for multiple myeloma. It's given as a tablet over a few months, alongside bortezomib and a steroid tablet.
Its main side effects include diarrhoea, fatigue and low blood counts. It can occasionally cause heart problems, but your haematologist will discuss the possible side effects with you.
Myeloma UK has more information on panobinostat.

Treating symptoms and complications of myeloma

As well as the main treatments for multiple myeloma, you may also need treatment to help relieve some of the problems caused by the condition. For example:
  • painkillers – to reduce pain
  • radiotherapy – to relieve bone pain or help healing after a bone is surgically repaired
  • bisphosphonate medicine given as tablets or by injection – to help prevent bone damage and reduce the levels of calcium in your blood
  • blood transfusions or erythropoietin medication – to increase your red blood cell count and treat anaemia
  • surgery – to repair or strengthen damaged bones, or treat compression of the spinal cord (the main column of nerves running down the back)
  • dialysis – may be required if you develop kidney failure
  • plasma exchange – treatment to remove and replace the liquid that makes up blood (plasma), if you have unusually thick blood
These treatments can each cause side effects and complications. Make sure you discuss the potential risks and benefits with your treatment team.

Clinical trials and research

Research is ongoing to find new treatments for multiple myeloma and work out ways to improve the use of existing ones. To help with this, you may be asked to take part in a clinical trial during your treatment.
Clinical trials usually involve comparing a new treatment with an existing one to see whether the new treatment is more or less effective.
It's important to remember that if you are given a new treatment, there's no guarantee it will be more effective than an existing treatment.
There will never be any pressure for you to take part in a trial if you don't want to.
Read more about clinical trials for myeloma on the Myeloma UK website.
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