The following section tells you about the treatments considered to be the standard care for multiple myeloma.
An Overview: Treatment
Doctors working in cancer care often work together to create an overall treatment plan for their patients. This is called a multidisciplinary team and it is done so that the patient receives a combination of treatments. In addition to doctors, cancer care teams can include social workers, oncology nurses, physician assistants, pharmacists, and dietitians.
Typically, a team of doctors will work with the patient to determine which is the best possible treatment plan, however, the treatment of multiple myeloma depends entirely on the patient’s overall health and whether they are experiencing any symptoms. While there is no cure for multiple myeloma, there are treatments that help to eliminate a patient’s myeloma cells and help to control pain and tumor growth, which allows the cancer to be managed successfully for many years.
Listed below are the treatment options for people who do not show any symptoms and for those with symptoms. Furthermore, treatment can depend on whether the patient is newly diagnosed or if they are experiencing a recurrence with multiple myeloma. Another important part of cancer care is the treatment of symptoms and side effects, therefore it is crucial that you take the time to learn about the various options, including clinical trials.
Treatment Options for Patients without Symptoms
If you have early-stage myeloma and you are not experiencing any symptoms, a doctor might just closely monitor you through checkups. This treatment is called active surveillance or watchful waiting. With that said, if a doctor notices bone thinning, or osteoporosis, he or she might recommend periodic infusions of bisphosphonates to reverse the process. If a patient begins to develop symptoms, active treatment will commence. In addition, there are clinical trials that help to identify and treat patients with “high-risk” SMM. High risk SMM patients are the people who are at risk of developing symptoms within 18 months to 2 years.
Treatment Options for Patients with Symptoms
If you have symptomatic myeloma, you will receive a treatment for the disease as well as supportive therapy to improve your quality of life, such as maintaining good nutrition and relieving symptoms. Stem cell transplantation is another option as well as disease-directed treatment which includes drug therapy, such as chemotherapy, with or without steroids. Treatment plans for patients with symptomatic myeloma have different phases including: induction therapy, consolidation, and maintenance therapy. First, induction therapy is for the rapid control of cancer and to help relieve symptoms and second, consolidation is done with more chemotherapy or stem cell transplant. Third, maintenance therapy is done over a prolonged period of time in order to prevent the cancer returning.
Targeted Therapy
As it blocks the growth and spread of cancer cells, targeted therapy treatment targets the cancer’s genes, proteins, or tissue that contributes to the cancer’s growth and survival. Targeted therapy has proven over the years to be successful at controlling the spread of myeloma and improving prognosis, however, researchers are continuing to investigate new drugs for the disease.
As recent studies have shown, not all tumors have the same end targets, therefore to find the most effective treatment, doctors will run tests on cancer cells to identify genes and proteins.
- Three drugs that stop the growth of myeloma cells in bone marrow include: (Revlimid), (), and (Synovir, Thalomid). These drugs attack cancer cells by strengthening the immune cells. In addition to strengthening immune cells, these drugs create angiogenesis, which is when the cancer cells are starved as the formation of new blood vessels gets blocked.
- Classified as proteasome inhibitors, (), carfilzomib (), and ixazomib (Ninlaro) target proteasomes, which are enzymes that digest proteins in cells. This is an attractive treatment option as myeloma cells produce a lot of proteins, meaning they are especially vulnerable to this type of drug.
- Histone Deacetylase (HDAC) is an enzyme that keeps DNA in a tight coil, while panobinostat (Farydak) is an inhibitor of the enzyme and it uncoils the DNA and activates the genes that slow or stop the growth of cancer cells. In addition, these drugs block the aggresome, which is an escape route.
- Two monoclonal antibodies that bind to myeloma cells are elotuzumab (empliciti) and daratumumab (darzalex). The patient’s immune system then labels the myeloma cells that need to be removed.
If you are a newly diagnosed patient, treatment options can include targeted therapies such as , , and . On the other hand, treatments that are effective for recurrent myeloma include , , , carfilzomib, panobinostat, ixazomib elotuzumab, and daratumumab. In addition, sometimes certain combinations of drugs can have a better effect than a single drug, so targeted therapies can be used with chemotherapy or steroid medications. For instance, the drugs and are offered in combination as initial treatment.
Furthermore, the drugs , , and can used as maintenance therapy following the initial therapy or stem cell transplant. If you are thinking about having a stem cell/bone marrow transplant, make sure that you carefully discuss it with your care team as it can be a complex procedure. Maintenance therapy has to be conducted with caution, however, studies have shown that maintenance therapy with and/or can increase how long a patient survives and how long they live without myeloma.
Additionally, before you take medication, it is important to talk to your doctor about the possible side effects and how you can manage them.
Chemotherapy – Drug Therapy
One of the most common forms of drug therapy is chemotherapy which uses drugs to destroy cancer cells by stopping the cell’s ability to grow. A patient can receive chemotherapy from a medical oncologist (specializes in treating cancer with medication), or a hematologist (specializes in treating blood disorders).
One type of chemotherapy is systemic chemotherapy which enters the bloodstream to reach the cancer cells throughout the body. This is not a targeted chemotherapy as the drugs affect the cancer cells as a whole. The most common way to administer chemotherapy is either through an IV tube that is placed into a vein or orally in which a pill or capsule is swallowed.
Patients enduring chemotherapy are given a regimen to follow which consists of a specific number of cycles given over a period of time. Depending on the patient and the severity of their condition, a patient could receive 1 drug at a time or a combination of different drugs.
Chemotherapy drugs that have been quite successful in treating myeloma include: cyclophosphamide (Cytoxan, Neosar), doxorubicin (Adriamycin, Doxil), melphalan (Alkeran), etoposide (Toposar, VePesid), cisplatin (Platinol), and carmustine (BiCNU).
Mentioned previously, it can be beneficial to combine chemotherapy with other treatment methods such as targeted therapies. For example, the combination of melphalan, , and can be used for the initial treatment of multiple myeloma.
Other Types of Drug Therapy
Like chemotherapy, steroids can also be administered at the same time as other drug therapy. For instance, if you are unable to have stem cell transplantation, doctors will recommend maintenance therapy with the drugs and .
Stem Cell and Bone Marrow Transplantation
If you have bone marrow that contains cancer, you will undergo a stem cell transplant in which the bone marrow is replaced by specialized cells (hematopoietic stem cells) and these cells then develop into healthy red blood cells, white blood cells, and platelets in the bone marrow. Contrary to popular belief, this procedure is known as a stem cell transplant, rather than bone marrow transplant, as it is the stem cells in the blood that are being transplanted, not the bone marrow tissue.
Before a doctor recommends a transplant, he or she will inform the patient of the risks and bring to light several other factors, such as the patient’s demographics, previous treatment results, and the type of cancer.
Doctors can recommend two types of stem cell transplantation, depending on the source of the replacement blood stem cells: allogeneic (ALLO) and autologous (AUTO). The primary difference between the two is that allogeneic uses donated stem cells, while autologous uses the patient’s stem cells. In terms of multiple myeloma, autologous is the more common one out of the two. However, both types have the same end goal, and that is to destroy all of the cancer cells in the marrow and blood by using high doses of chemotherapy. After chemotherapy, replacement blood stem cells will create healthy bone marrow.
Radiation
If you have bone pain but chemotherapy is not effective and the pain needs to be controlled, your doctor may recommend radiation therapy. Radiation therapy destroys cancer cells by blasting them with high-energy x-rays. For instance, external-beam radiation therapy is radiation given from a machine outside the body, and it is the most common type of radiation therapy.
If you are undergoing radiation, you will be given a regimen to follow which consists of a specific number of treatments given over a period of time.
With that said, deciding to endure radiation therapy is not always an easy decision. In some cases, pain can occur due to the damage to the bone. Another factor to consider before saying yes to radiation is the various side effects. These side effects may include fatigue, upset stomach, mild skin reactions, and loose bowel movements. Don’t let this discourage you though, most of these side effects will go away as soon as the treatment is over.
Operations
Though it is not a treatment option for multiple myeloma, surgery can be used to relieve various symptoms. For example, if you have bone disease and there are fractures or recent plasmacytomas, then you can undergo surgery.
Symptoms and Side Effects
Unfortunately, cancer and its treatments can cause side effects and helping to relieve a person’s symptoms and side effects is equally as important in cancer care. Healthcare professionals refer to this approach as palliative or supportive care, and it focuses on supporting a patient’s physical, emotional, and social needs.
Any treatment that focuses on improving a patient’s quality of life or reducing their symptoms is palliative care. Anyone can receive palliative care, however, it is recommended to start as early as needed in the cancer treatment process. Studies have shown that patients who receive treatment for the cancer and for the side effects at the same time often have less severe symptoms, a better quality of life, and they feel more satisfied with the treatment.
Generally speaking, palliative treatments can include medication, relaxation techniques, nutritional changes, or emotional support. If you have myeloma, palliative care may include:
- Using antibiotics and intravenous immunoglobulins to treat and prevent infections
- Pain medication can be administered to patients who need help dealing with bone pain. Non-steroidal anti-inflammatory drugs should be avoided but there are a wide range of drugs that can be used, including Tylenol and opiates.
- When dealing with viral infections, especially for those being treated with a proteasome inhibitor, antiviral medications can be used to treat or prevent further infection.
- For patients who are being treated with a combination of an immunomodulatory agent, a blood thinner will help to prevent blood clots
- Antidepressants are prescribed to patients to help them cope with the cancer diagnosis as well as to treat neuropathy (caused by the myeloma itself or by treatments for myeloma)
- If a patient is dealing with bone pain, bisphosphonates are drugs that can be administered to help increase bone density and reduce the risk of fractures.
Additionally, it is possible for a patient to receive palliative treatments that are similar to those meant to eliminate cancer, such as chemotherapy, surgery, or radiation therapy. For instance, surgery can be used to relieve pressure from a plasmacytoma on the spine.
It is crucial that you talk to your doctors before treatment begins so you can learn more about the potential side effects of your treatment plan and what options you have for palliative care. Additionally, make sure that you tell your healthcare team if you are experiencing problems during and after treatment.
Relapsed and Refractory Myeloma
If the cancer no longer responds to the most recent treatment, the disease is called relapsed and refractory myeloma. Doctors might have different opinions on what the best treatment plan is, therefore, if this happens, try talking with a doctor that has experience in treating refractory myeloma.
For those with refractory myeloma, sometimes there are drugs that are awaiting FDA approval that can be made available to patients through FDA’s Expanded Access Clinical Trial Program. For instance, the drug daratumumab was approved in 2015 to be used alone to treat relapsed myeloma after other treatments failed. Palliative care to relieve symptoms and side effects is also available for those with refractory myeloma. As always, make sure you talk to your physician about which drugs are available.
Since most patients have a difficult time after hearing a diagnosis of relapsed and refractory myeloma, it is recommended that patients and their families talk about the diagnosis with either doctors, nurses, members of their health care team, or other patients.
Remission and Recurrence
Remission can be a temporary or permanent state in which the cancer is not detected in the body and there are no symptoms. Due to this uncertainty, many people worry that the cancer will come back. Despite the advances in myeloma therapy, the possibility of the cancer returning is almost certain with myeloma, therefore it is important that you understand your risk of recurrence so you feel more prepared if the cancer does return.
If the cancer returns after completing the initial treatment, it is called recurrent or relapsed myeloma. First, if the cancer returns, a cycle of testing will begin in order to learn as much as possible about the recurrence. Second, after the testing is done, you will be able to discuss your treatment options with your healthcare team. Additionally, your doctor may suggest clinical trials that are studying new ways of treating recurrent or relapsed myeloma.
The Possibility of Treatment Failing
Despite recent advances, myeloma is still considered to be incurable. If the cancer cannot be controlled with the treatments that are available, the disease might be labelled advanced or terminal.
Terminal cancer is a difficult subject to discuss for many people, however, it is crucial that you have open conversations with your healthcare team. Keep mind that this team is there to help you and they accommodate your feelings, preferences, and concerns.
If a patient has advanced cancer with a life expectancy of less than 6 months, it is recommended that they look into hospice care, which is designed to provide the best quality of life for people who are near the end. Additionally, if the patient wants to remain at home, there are options such as nursing care and special equipment that make staying at home a workable alternative.
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