Multiple myeloma - Treating multiple myeloma

If you have multiple myeloma, you will be cared for by a team of healthcare professionals usually led by a consultant haematologist who specialises in myeloma.

The team will discuss your condition and recommend what they think is the best treatment for you. However, the final decision will be yours.

Before visiting hospital to discuss your treatment options, it may be useful to write a list of questions that you would like to ask the specialist. For example, you may want to find out the advantages and disadvantages of a particular treatment.

There are two main aims in treating multiple myeloma. These are to:

bring the myeloma under control using various combinations of anti-myeloma treatments that remove the cancerous cells from your bone marrow
treat the symptoms associated with myeloma, such as anaemia and bone pain

Bringing myeloma under control

Not everyone diagnosed with myeloma will need immediate treatment if the condition is not causing any problems. This is sometimes referred to as asymptomatic or ‘smouldering myeloma’.

If you do not need treatment, you will be actively monitored for signs the cancer is beginning to cause problems. If you do need treatment, the options outlined below are most commonly used.

It is important to understand that although myeloma is treatable, for most people it is not currently curable. This means that additional treatment is always required when the cancer comes back. The most commonly used treatments for when myeloma reoccurs are also described below.

Initial treatment for myeloma may either be:

non-intensive – for older or less fit patients
intensive – for younger or fitter patients

There is no particular age cut-off for who can have intensive treatment and who can have less-intensive treatment, and this is usually a decision based on the biological age (or fitness) of the individual.

However, as a general rule, people younger than 65 are more likely to be candidates for intensive therapy. For those over 70, non-intensive treatment is more likely to be recommended. Those aged in between will be given careful consideration as to what treatment group they fall into.

Both treatment intensities are very effective, but intensive treatment is thought to be too toxic for older or less fit patients.

All patients who require treatment will almost certainly aim to start with a combination of three anti-myeloma medicines.

These medicines all have different ways of working and work very effectively together at killing myeloma cells (much more effectively than if they were given on their own).

In the younger, or fitter, group of patients, this is called induction treatment because it is almost always followed by additional treatment known as high-dose therapy and stem cell transplantation (see below).

In the older, or less fit, group this treatment is referred to as initial or frontline treatment. It is almost always identical to the induction treatment given in the younger/fitter group, but some of the medicines may be given in modified doses or timings.

These treatment combinations usually consist of three medicines, including a chemotherapy medicine (either melphalan or cyclophosphamide), a steroid medicine (dexamethasone or prednisolone) and either thalidomide or velcade.

Together with your consultant haematologist, your team will decide the most appropriate combination that best suits your myeloma and personal preferences. The medicines are described in more detail below.

Steroids

Steroid medication is similar to a type of hormone found naturally in the body. Dexamethasone and prednisolone are steroids often used to treat myeloma. The steroids work by killing the cancerous plasma cells that develop in the bone marrow.

Steroids are taken orally (by mouth) and are best taken at breakfast with food. Possible side effects include heartburn, indigestion, mood changes and problems falling asleep.

Thalidomide

Thalidomide is a medication that was introduced in the 1950s to treat morning sickness, but it was later found to cause birth defects. However, research has shown that thalidomide can be effective in killing myeloma cells.

Thalidomide tablets are usually taken during the evening with food. Due to the risk of causing birth defects, it is important to use reliable contraception, such as a condom, while taking thalidomide.

It is likely you will have to sign a confirmation form stating you are aware of the risks of birth defects and of the precautions you need to take.

Common possible side effects of thalidomide include:

sleepiness
constipation
loss of appetite
headaches
skin rashes
numbness or tingling in the hands and feet

There is also a risk you may develop a blood clot when taking thalidomide. Therefore, you may be given aspirin or low molecular weight heparin to help prevent blood clots.

Contact a member of your cancer team immediately if you develop pain or swelling in one of your calves, or if you have chest pain and/or breathlessness.

Chemotherapy

Chemotherapy works in a number of different ways to directly kill myeloma cells. The two most common types of chemotherapy used to treat myeloma are melphalan and cyclophosphamide. These two medicines work in a similar way and are sometimes used interchangeably.

These treatments are mostly given by mouth. They are reasonably well tolerated and side effects are mild. Possible common side effects include:

infection (see below)
nausea
vomiting
hair loss
tummy upsets

Your clinician will give you specific dietary advice and information about your risk of developing potentially serious infections.

Bortezomib

Bortezomib belongs to a relatively new class of anti-cancer medicines called proteasome inhibitors. It is particularly effective against myeloma cells.

All cells have an internal recycling protein known as the proteasome. Cells depend on this to recycle the things they need to grow and to dispose of the things that may be harmful to their survival.

Bortezomib blocks the functioning of proteasome, causing the myeloma cell to die.

Possible side effects of bortezomib include:

tiredness
nausea
diarrhoea
numbness or tingling in your hands and feet

There are some limitations as to which newly diagnosed patients should get bortezomib, but your doctor or nurse will discuss this with you.

Your doctor or nurse will tell you about your treatment and possible side effects to look out for. As with all treatments, it is important to let your doctor or nurse know of any side effects immediately.

Intensive treatment

Intensive treatment involves giving a much higher dose of chemotherapy in an attempt to destroy a larger number of myeloma cells, resulting in a longer period of remission (where there is no sign of active disease in your body).

However, as this treatment approach also knocks down healthy bone marrow, stem cells are transplanted to rescue the bone marrow. This treatment is known as high-dose therapy and stem cell rescue or transplantation.

In most cases, stem cells will be collected from the patient before they have the treatment (autologous transplantation). In rare cases, the cells are collected from a sibling (brother or sister) or an unrelated donor (sibling or match unrelated donor transplantation). An unrelated transplant is usually only performed after an autologous transplant.

Intensive treatment is associated with significant side effects and requires a two to three week stay in hospital and a three to six month recovery period, or an autologous transplant.

A transplant from another person can be much more complex so is not usually a treatment option for older people or those with a poor level of fitness.

Maintenance treatment

Maintenance treatment is occasionally given to prolong treatment benefits. However, further research is underway to establish its role in the treatment of myeloma, which patients require maintenance, and who are most likely to benefit. It is not currently standard practice in the UK.

Treating the symptoms and complications of myeloma

Radiotherapy

Radiotherapy can be used to help relieve bone pain. It involves directing high-energy waves of radiation at bones weakened and damaged by cancerous cells.

The radiation reduces the number of cancerous cells in the bone, giving the bone a chance to repair itself. You should only need one to two sessions of radiotherapy to reduce the pain. However, longer courses are often used if there is compression of the spinal cord.

The side effects of radiotherapy usually pass after the course of radiotherapy has been completed. Depending on the dose given and the site treated, side effects can include nausea, sickness, skin rashes, pain and tiredness.

Bisphosphonates

Bisphosphonate medication can be used to help prevent bone damage and reduce the levels of calcium in your blood.

Bone usually goes through a continuous cycle of repair, where the body replaces old bone cells with new ones.

In myeloma, cancerous plasma cells disrupt this process, causing the bones to weaken. Bisphosphonates help to stop this happening and reduce both fractures and pain. Recent evidence suggests they may also have effects on survival.

Read more about the Medical Research Council’s Myeloma IX trial: the impact on treatment paradigms.

Bisphosphonates are either given as tablets or by injection. The most common side effects include stomach pain, nausea, vomiting and diarrhoea. You should speak to your cancer team if you are finding any of these side effects troublesome.

Treatments for anaemia

If you have anaemia as a result of having a low number of red blood cells, blood transfusions can be used to increase your red blood cell count.

In certain situations, you may also be given a medication called erythropoietin to encourage production of new red blood cells.

Surgery

In some cases, surgery may be needed to repair or strengthen damaged bones. Compression fractures of the spine may be treated using two fairly new surgical techniques known as:

percutaneous vertebroplasty – where a special type of quick-drying cement is injected into the affected bone to strengthen it and reduce the risk of fracture
balloon kyphoplasty – where a tiny balloon is inserted into the affected vertebra (bone of the spine), inflated and removed, and then the space is filled with a special type of cement

The National Osteoporosis Society provides more information about percutaneous vertebroplasty and balloon kyphoplasty (PDF, 175kb).

Relapse treatment

When the myeloma returns, you will be given an additional course of a combination of anti-myeloma treatments. This usually involves two or three medicines to try to control the myeloma again.

Treatment for relapsing myeloma is based on the same principles as those used for treating newly diagnosed myeloma and the treatment itself is also similar.

However, high-dose therapy and stem cell transplantation in younger, or fitter, patients is less commonly used, but is increasingly being considered as an option in patients who have had a sustained response to a first autologous transplant. Therefore, most patients, regardless of age and fitness, are treated similarly.

All the medicines described above are used in various combinations to treat relapsed myeloma. However, the important points below are worth noting.

Bortezomib is only approved for your first relapse, and patients must achieve a certain response to be able to continue treatment. Your doctor or nurse will explain this to you.
A medicine called lenalidomide (Revlimid) has recently been approved for treating adult multiple myeloma patients who have received at least one prior therapy (see below).

Lenalidomide

Lenalidomide works in a similar way to thalidomide in that it blocks the blood supply to the cancerous cells, and also helps the immune system fight the myeloma.

However, as lenalidomide can reduce the number of white blood cells in your blood, you will be more vulnerable to infection.

You should let your care team know if you think you may have an infection – for example, if you have a high temperature or if you feel unwell.

Lenalidomide also reduces the number of platelets in your blood, which means your skin can be easily bruised and you can bleed easily. Again, you should report these symptoms to a member of your care team.

If you are taking lenalidomide there is risk of developing a blood clot. Contact a member of your cancer team immediately if you develop pain or swelling in one of your calves, or if you have chest pain or breathlessness.

Read more about the European Medicines Agency’s 2013 approval of lenalidomide for treating patients with multiple myeloma.

Clinical trials

Cancer treatments have improved considerably over the past few decades. Some of these improvements have been due to patients taking part in clinical trials. Myeloma is a good example of this. Therefore, you may be asked to take part in a clinical trial.

Clinical trials usually involve comparing a new treatment with an existing treatment to see whether the new treatment is more or less effective.

It is important to remember that if you are given a new treatment there is no guarantee it will be more effective than an existing treatment.

There will also never be any pressure for you to take part in a trial if you do not want to.

Search clinical trials for multiple myeloma.