When first diagnosed with myeloma, not everyone will need treatment to control their myeloma immediately. As currently available treatment is not curative and has side-effects, it is usual to wait until the myeloma is actively causing complications before beginning treatment.
When first diagnosed people with myeloma will be given initial treatment, this can be generally categorised into two groups:
- 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.
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 intensive treatment).
In the older, or less fit, group this treatment is referred to as initial or frontline treatment.
In general the treatment of myeloma can be thought of in three different groups. These are:
- Anti-myeloma treatments
- Supportive care treatments
- Active monitoring
On completion of some or all of the tests described above, your doctor should have a clear and comprehensive picture of the specific characteristics of your myeloma. The presence of complications, caused by the myeloma damaging specific organs and tissues of the body, can also help to determine the characteristics of your myeloma. These are usually referred to by the acronym ‘CRAB’ which describes the four main complications that are generally observed in myeloma:
R-renal (kidney) impairment
B-bone damage (lytic lesions)
Results from the tests and investigations listed above, together with CRAB, will help decide when treatment should begin, what that treatment should be, and provide a baseline against which response to treatment and disease progression can be measured.
The Myeloma Multi-Disciplinary team will discuss your condition and recommend what they think is the best treatment for you. However, the final decision will be yours.
There are two main objectives in treating myeloma. These are to:
- bring the myeloma under control using numerous combinations of anti-myeloma treatments that remove the cancerous cells from your bone marrow
- treat the symptoms associated with myeloma such as bone pain
This is to control the myeloma itself. Treatment is usually most effective when two or more drugs are combined. These drugs have different but complementary mechanisms of action.
There are various anti-myeloma treatments available, which are used at different stages of myeloma and in different combinations. These include
- Lenalidomide (Revlimid)
- Bortezomib (Velcade)
- High-dose therapy and stem cell transplantation
Chemotherapy (chemo) is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells, and can be given: as tablets; into a vein (‘intravenously’); or as an injection under the skin (‘subcutaneously’).
Side-effects can include nausea, vomiting, diarrhoea, sore mouth, infections and hair loss. Some chemotherapy drugs can cause infertility, if this is a consideration for you, you should speak to your doctor.
Examples of commonly used chemotherapies include cyclophosphamide, melphalan. These are most commonly given in tablet form or intravenously.
It is recognised that steroids are effective in killing myeloma cells. It is most commonly given in tablet form but can also be given intravenously.
Side-effects can include stomach pain, raised blood sugar, increased appetite, change in mood, increased risk of infection and muscle weakness.
The most common steroids given are dexamethasone and prednisolone.
Given as a tablet, usually in the evening. Side-effects can include constipation, drowsiness and peripheral neuropathy. Peripheral neuropathy is damage to the nerves in the hands and feet resulting in tingling, numbness, increased sensitivity and pain.
Given as a tablet, usually in the evening.
Side-effects can include GI disturbances, cramps, peripheral neuropathy and low blood counts.
Can be given intravenously but most commonly given as a subcutaneous injection in the outpatient chemotherapy department.
Side-effects can include peripheral neuropathy, reduction in white blood cells, diarrhoea, skin rash, fatigue.
The following treatment combinations usually consist of three medicines, including chemotherapy (i.e. melphalan or cyclophosphamide), a steroid (i.e. dexamethasone or prednisolone) and an iMiD or proteasome inhibitor (i.e. thalidomide or velcade.)
Your specialist doctor will explain which treatment combination is appropriate for you, but if you ever feel unsure of what is being offered or why, you can consider seeking a second opinion. It is important to feel happy with the options that have been recommended and to have a good understanding of what is to follow.
Intensive treatment involves giving a much higher dose of chemotherapy. The aim of this treatment is 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 given via an infusion 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 (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.
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.
This is when anti-myeloma treatment is not required as the condition is not causing any symptoms or complications. This is sometimes referred to as asymptomatic or ‘smouldering myeloma’.
This can also happen once initial therapy is completed and the myeloma is under control. You will be actively monitored for signs and symptoms the cancer is beginning to cause problems.
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.
When treatment is required again, the same principles are used when treating newly diagnosed myeloma. Treatment is likely to be a combination of the anti-myeloma therapies described previously.
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.
Supportive care treatments are given to control and relieve complications and symptoms caused by myeloma. These include:
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 anti-myeloma effect and survival benefit. .
Bisphosphonates are commonly given as an intravenous infusion. The most common side effects include fever and flu-like symptoms, nausea, impaired renal function. A rare side-effect is osteonecrosis of the jaw (ONJ), where bones of the jaw become damaged; you should let your dentist know that you are receiving bisphosphonates. You should speak to your myeloma team if you are finding any of these side effects troublesome.
Radiotherapy can be used to help relieve bone pain. It involves directing high-energy waves of radiation at bones that have been 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. One to two sessions of radiotherapy are normally required 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
Treatments for anaemia
If you have anaemia as a result of having a low number of red blood cells due to your myeloma or treatment, you may be given a blood transfusion.
In certain situations, you may also be given a medication called erythropoietin to encourage production of new red blood cells.
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