Multiple Myeloma

Last Updated: April 21, 2008

This section has been reviewed and approved by the Cancer.Net Editorial Board,  03/08

Overview

Myeloma is a cancer of the plasma cells in the bone marrow, the spongy tissue inside of bones. Plasma cells are a part of the body's immune system and produce antibodies that help the body fight infection. Abnormal plasma cells can suppress the growth of other cells in the bone that produce red blood cells, white blood cells, and platelets. This suppression may result in anemia (from a shortage of red blood cells), excessive bleeding from cuts (from a shortage of platelets), and a decreased ability to fight infection (from a shortage of white blood cells). Myeloma often causes structural bone damage resulting in painful fractures. Like regular plasma cells, myeloma cells can produce antibodies. However, as the myeloma cells grow uncontrollably, there is overproduction of antibodies, leading to an accumulation in the blood and urine that may cause kidney and other organ damage.

Myeloma is often called multiple myeloma because most people (90%) have multiple bone lesions at the time it is diagnosed. Solitary plasmacytoma is a mass of myeloma cells that involve only one site in the bone or other organs (most commonly the upper respiratory tract, including the nose and throat). Extramedullary plasmacytoma describes myeloma that started outside of the bone marrow, such as the lymph glands, sinuses, throat, liver, or under the skin.

Statistics

In 2009, an estimated 20,580 adults (11,680 men and 8,900 women) in the United States will be diagnosed with multiple myeloma. It is estimated that 10,580 deaths (5,640 men and 4,940 women) from this disease will occur this year.

The five-year relative survival rate (percentage of people who survive at least five years after the cancer is detected, excluding those who die from other diseases) of people with multiple myeloma is about 35%.

Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of cases of this type of cancer, but the actual risk for a particular individual may differ. It is not possible to tell a person how long he or she will live with multiple myeloma. Because the survival statistics are measured in five-year intervals, they may not represent advances made in the treatment or diagnosis of this cancer.

Statistics adapted from the American Cancer Society's publication, Cancer Facts and Figures 2009.

Find out more about basic cancer terms used in this section.

Medical Illustrations

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Risk Factors

A risk factor is anything that increases a person’s chance of developing cancer. Some risk factors can be controlled, such as smoking, and some cannot be controlled, such as age and family history. Although risk factors can influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and communicating them to your doctor may help you make more informed lifestyle and health-care choices.

The causes of myeloma are not known or well understood, and there are currently no known ways to prevent it. There are also no strong risk factors for myeloma. Mutations in plasma cells are acquired, not inherited, so having a relative with the disease usually does not mean another family member is at higher risk for developing it. There appears to be a very slight increase in the incidence of the disease in first-degree relatives (parents or siblings) of people with multiple myeloma, but this link is controversial.

The following factors can raise a person's risk of developing myeloma:

Age. Myeloma occurs most commonly in people over 60. The average age at diagnosis is 70. Only 2% of cases occur in people under 40.

Race. Myeloma occurs twice as frequently in black people than in white people for unclear reasons.

Exposure to radiation and chemicals. People who have been exposed to radiation or to asbestos, benzene, pesticides, and other chemicals used in rubber manufacturing may be at higher risk for developing myeloma.

Individual history. People with a history of a solitary plasmacytoma are at greater risk for developing multiple myeloma.

Monoclonal gammopathy of unknown significance (MGUS). This is when a person has a low level of a certain protein in his or her blood, called the M protein. People with this condition have a 20% to 25% chance of developing myeloma or lymphoma. (See Staging)

Gender. Myeloma is slightly more common in men.

Symptoms

People with multiple myeloma may experience the following symptoms. Sometimes, people with multiple myeloma do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. If you are concerned about a symptom on this list, please talk with your doctor.

• Fatigue is usually caused by anemia and occurs in most people with myeloma. Anemia is a low level of red blood cells, which happens when the myeloma plasma cells crowd out normal red blood cells.
  
  
• Bone pain, a common symptom, is caused by local bone damage and osteoporosis (general thinning of the bone), which makes the bone more likely to break. The back or ribs are the most common sites of bone pain, but any bone can be affected. Pain is usually worse with movement and at night. If cancer is in the spine, the vertebrae (individual bones that make up the spine) can collapse and cause nerve pain. In advanced multiple myeloma, a patient may lose inches from his or her height due to compressed vertebrae.
  
  
• Kidney damage or failure
  
  
• Weight loss, nausea, thirst, muscle weakness, and mental confusion symptoms are related to kidney failure, hypercalcemia (high calcium levels in the blood), or other imbalances in blood chemicals.
  
  
• Hypercalcemia, resulting in symptoms of drowsiness, constipation, and kidney damage
  
  
• Infections, especially of the upper respiratory tract and lungs
  
  
• Blood clots, nosebleeds, bleeding gums, bruising, and hazy vision caused by hyperviscosity (thickened blood)

Diagnosis

Doctors use many tests to diagnose cancer and determine if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:

• Age and medical condition
• The type of cancer suspected
• Severity of symptoms
• Previous test results

In addition to a physical examination, the following tests may be used to diagnose multiple myeloma:

Blood and urine tests. Myeloma cells secrete an antibody known as the M protein (monoclonal immunoglobulin). Levels of the M protein in a patient's blood and urine are used to determine the extent of the disease and to monitor the effectiveness of treatment. Blood tests are also used to measure kidney function, calcium levels, and blood counts (for possible anemia).

Bone marrow biopsy. In a bone marrow biopsy, a needle is inserted through the skin into the back of the pelvic (hip) bone to remove a small amount of tissue. The tissue is then examined under a microscope by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease). To minimize pain during the procedure, a local anesthesia is given to numb the area or the patient may be sedated.

Fat pad aspirate. If amyloidosis (a disorder where certain proteins accumulate in body tissues and organs) is a consideration, it may be necessary to take a sample of the abdominal fat pad (the collection of fat around a person's abdomen) for examination under a microscope, called a biopsy.

Imaging

X-ray. An x-ray is a picture of the inside of the body. X-rays are typically the first step in evaluating myeloma in the bones.

Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. An MRI can show replacement of normal bone marrow by myeloma cells or plasmacytoma (a plasma cell tumor growing in bone or soft tissue), especially in the skull, spine, and pelvis. The detailed images may also show compression fractures of the spine or a tumor pressing on nerve roots. A contrast medium (a special dye) may be injected into a patient’s vein to create a clearer picture.

Computed tomography (CT or CAT) scan. A CT scan creates a detailed, cross-sectional view that shows any abnormalities or tumors in soft tissues. A computer then combines these images into a three-dimensional picture of the inside of the body. Sometimes, a contrast medium is injected into a patient’s vein to provide better detail, but it is used cautiously in patients with multiple myeloma because of a risk of kidney failure

Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body and absorbed by the organs or tissues being studied. This substance gives off energy that is detected by a scanner, which produces the images.

Bone scan. A bone scan uses a radioactive tracer to look at the inside of the bones. The tracer is injected into a patient’s vein. It collects in areas of the bone and is detected by a special camera. Healthy bone appears gray to the camera, and areas of injury, such as those caused by cancer, appear dark.

To learn about the terms used in this section, read the Cancer.Net Feature: Cancer Terms to Know: Newly Diagnosed.

To learn more about what to expect during common diagnostic tests, read Cancer.Net: Tests and Procedures.

Staging

Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and if it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery). There are different stage descriptions for different types of cancer.

The Durie-Salmon system has been traditionally used for the staging of myeloma. This staging system is good for assessing the extent of the disease or size of the tumor. According to this system there are three stages; each stage is further subclassified into A or B depending on whether kidney function has been affected (with the subclassification B meaning there is significant kidney damage).

Some doctors have proposed a new classification system called the International Staging System (ISS), which defines the factors that influence patient survival. The ISS is based on data collected from patients with multiple myeloma from around the world. The system has three stages based on the serum albumin (a blood protein made by the liver that is necessary for maintaining proper blood volume) measurements and serum ß2-microglobulin (ß2-M) (a small protein that plays a role in immunologic defense) levels. Recent efforts involve classifying myeloma based upon patterns of gene expression in myeloma cells. It is also becoming more common to classify people with myeloma as symptomatic (having symptoms) versus asymptomatic (without symptoms).

Stage I

Many patients with stage I myeloma show no symptoms because there are fewer cancer cells in the body. If the cancer has affected kidney function, the prognosis may be worse regardless of the stage. Factors characteristic of stage I include:

• Number of red blood cells within or slightly below normal range
  
  
• Normal amount of calcium in the blood
  
  
• Very low levels of M protein in the blood or urine
  
  
• No bone damage on x-rays
  
  
• ß2-M less than 3.5 grams per deciliter (gm/dL) and albumin greater than or equal to 3.5 gm/dL

Stage II

More cancer cells are present in the body in stage II. Again, if kidney function is affected, then the prognosis worsens regardless of the stage. Criteria for stage II are defined as those that fit neither stage I nor stage III.

Stage III

Many cancer cells are present in the body at stage III. Factors characteristic of this stage are:

• Anemia with a hemoglobin less than 8.5 gm/dL
  
  
• Hypercalcemia
  
  
• Advanced bone damage (more than three bone lesions)
  
  
• High levels of M protein in the blood or urine, which is defined as:
  
  IgG value greater than 7gm/dL
  IgA value greater than 5gm/dL
  Urine light chain M component on electrophoresis greater than 12gm/24h
  
  
• ß2-M greater than 5.5 gm/dL

Recurrent

Recurrent myeloma is myeloma that comes back after treatment.

Other classifications

Some people have no symptoms of myeloma, but they may have abnormal plasma cells producing an abnormal protein (M protein). Doctors generally monitor these people closely and do not actively treat them unless this condition turns into symptomatic myeloma.

Monoclonal gammopathy of unknown significance (MGUS)

This condition occurs when people have a low level of M protein (meaning there are small quantities of abnormal plasma cells), but they do not have any other evidence of myeloma, such as bone damage, excessive plasma cells, or low numbers of red blood cells. People with MGUS have a 20% to 25% chance of developing myeloma or lymphoma in the future. For this reason, doctors closely monitor the health of people with MGUS.

Smoldering multiple myeloma (SMM) or asymptomatic myeloma

People who are diagnosed with SMM have slightly higher levels of M protein and more plasma cells in the bone marrow than people with MGUS. There is still no evidence of symptoms or signs of myeloma, such as bone disease or anemia. Most people with SMM eventually develop myeloma.

Prognosis

The International Staging System (ISS) of myeloma gives information about prognosis and predicts the chance of recovery. Researchers are also looking at other ways to predict prognosis for patients with multiple myeloma. Some of these ways of evaluating prognosis include:

• High levels of ß2-M may indicate a large number of myeloma cells are present and kidney damage has occurred. The level of this protein increases as myeloma becomes more advanced.
  
  
• Lower amounts of serum albumin may indicate a poorer prognosis.
  
  
• Lactase dehydrogenase (LDH) is an enzyme; higher blood levels of LDH indicate a poorer prognosis.
  
  
• Abnormalities of chromosomes in the cancer cells may show how aggressive a cancer is.
  
  
• A plasma cell labeling index can be done in a specialized laboratory using bone marrow samples, to find out how fast the cancer cells are growing.

Treatment

The treatment of multiple myeloma depends on many factors. In many cases, a team of doctors will work with the patient to determine the best treatment plan. The goals of treatment are to eliminate myeloma cells, control tumor growth, control pain, and allow patients to have a normal, active life.

This section outlines treatments that are the standard of care (the best treatments available) for this specific type of cancer. Patients are also encouraged to consider clinical trials when making treatment plan decisions. A clinical trial is a research study to test a new treatment to prove it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, visit the clinical trials section.

While there is no cure for multiple myeloma, the cancer can be managed successfully in many patients for years. Doctors help patients manage the symptoms of myeloma as if it were a chronic disease, so patients can lead a normal life.

Patients with MGUS, or with early stage myeloma and no symptoms, may simply be closely monitored. This approach is called active surveillance, watchful waiting, or watch-and-wait. If symptoms appear, then active treatment starts. Current research shows that active therapy for people with no symptoms does not result in longer survival. However, patients with asymptomatic myeloma may participate in clinical trials designed to prevent the disease from turning into active myeloma.

Treatment for patients with symptomatic myeloma includes disease-specific treatment and supportive therapy (therapy to manage symptoms and maintain nutrition during treatment). Disease-specific treatment includes chemotherapy with or without steroids, as well as novel agents such as bortezomib (Velcade), and thalidomide (Thalomid). Radiation therapy may be used to help with symptoms and to shrink tumors. Lenalidomide (Revlimid) and bortezomib (Velcade) are effective for treating recurrent myeloma; lenalidomide is also being evaluated to treat newly diagnosed patients. Stem cell transplants may also be an option for myeloma. Each treatment is described below.

Most patients with myeloma receive monthly infusions of bisphosphonate therapy, drugs that help to prevent bone disease from myeloma. For more information, please see ASCO's Patient Guide on Bisphosphonates for Multiple Myeloma.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished. The length of chemotherapy treatment varies from patient to patient and is usually given until the myeloma is well controlled.

Chemotherapy that has been used successfully for the treatment of myeloma through the years include cyclophosphamide (Cytoxan, Neosar), doxorubicin (Adriamycin), melphalan (Alkeran), vincristine (Oncovin), cisplatin (Platinol), and dexamethasone (Decadron). These drugs are often used in combination.

The combination of melphalan, prednisone, and bortezomib is approved by the U.S. Food and Drug Administration (FDA) for the initial treatment of multiple myeloma because it increased survival when compared with melphalan and prednisone. In Europe, the combination of melphalan, prednisone, and thalidomide also looks promising. Additional combinations of drugs are being evaluated in clinical trials.

The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions through Cancer.Net's Drug Information Resources, which provides links to searchable drug databases.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. Doctors may recommend radiation therapy for patients with bone pain when chemotherapy is not effective or in an attempt to control pain.

The use of radiation therapy should be a careful decision. In many instances, pain (especially back pain) is due to structural damage to the bone. Radiation therapy will not help this type of pain and may compromise the bone marrow's response to chemotherapy in future treatment.

Side effects of radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished.

Surgery

Because multiple myeloma is usually widespread and scattered at the time of diagnosis, surgery is not used to treat myeloma. It may be used to diagnose the disease or relieve pressure from a plasmacytoma on the spine or other organs. More recently, procedures such as kyphoplasty (inflating and injecting bone cement into the vertebral bodies) have been considered to relieve pain, restore lost height from collapsing vertebral bodies, and strengthen the spine.

Stem cell transplantation/bone marrow transplantation

A stem cell transplant is a medical procedure in which diseased bone marrow is replaced by highly specialized cells, called hematopoietic stem cells. Hematopoietic stem cells are found both in the bloodstream and in the bone marrow. Today, this procedure is more commonly called a stem cell transplant, rather than bone marrow transplant, because blood stem cells are typically what is being transplanted, not the actual bone marrow tissue.

There are two types of stem cell transplantation depending on the source of the replacement blood stem cells: allogeneic (ALLO) and autologous (AUTO). AUTO is a standard treatment for myeloma, while ALLO is recommended only for patients with high-risk or recurrent disease.

In an ALLO transplant, stem cells are obtained from a donor whose tissue matches the patient’s on a genetic level; this testing is called HLA-typing. Most often, a patient’s brother or sister serves as the donor, although unrelated donors can serve as the donor, too. Millions of people worldwide have volunteered to donate stem cells for patients who do not have matched family members; matches can be made by searching a computer registry. In addition, a donation of stem cells derived from umbilical cord blood is sometimes considered if family donors are not available.

In an AUTO transplant, the patient’s own stem cells are used. The stem cells are obtained from the patient when he or she is in remission from previous treatment. The stem cells are then frozen until they are needed, usually after the high-dose treatment (explained below) is completed.

In both types, the goal of transplantation is to destroy cancer cells in the marrow, blood, and other parts of the body and have replacement blood stem cells create healthy bone marrow. In most stem cell transplants, the patient is treated with high doses of chemotherapy and/or radiation therapy to destroy as many cancer cells as possible. This also destroys the patient’s bone marrow tissue and suppresses the patient’s immune system so that, in an ALLO transplant, the donor cells are not rejected by the body. After the high-dose treatment is given, blood stem cells are infused into the patient’s vein to replace the bone marrow and restore normal blood counts from donor cells. Sometimes, ALLO transplants can also be performed after giving lower doses of chemotherapy and/or radiation therapy that are still sufficient to suppress the immune system and allow growth of the donor cells. (These transplants, sometimes termed “mini-transplants” or “reduced intensity transplants” have less immediate side effects, allowing the procedure to be used for older patients.)

Before recommending transplantation, doctors will talk with the patient about the risks of this treatment and consider several other factors, such as the type of cancer, results of any previous treatment, and patient’s age and general health.

For both ALLO and AUTO transplant types, the replacement cells engraft (begin to make new blood cells) and turn into healthy, blood-producing tissue in two to three weeks. Destroying the patient’s own marrow reduces the body’s natural defenses, temporarily leaving the patient at an increased risk of infection. Until the patient’s immune system is back to normal, patients may need antibiotics and blood transfusions.

In an ALLO transplant, another major risk is that the donor’s cells will recognize the patient’s body as foreign, causing graft-versus-host disease (GVHD). GVHD may be a serious complication of allogeneic transplants and can be fatal. Other side effects may include liver problems, diarrhea, infections, and rashes. However, GVHD can also be a benefit, in that the donor cells can recognize the cancer cells as foreign and destroy these cells, a mechanism that is one of the major reasons why ALLO transplantation generally works so well over the long term. The risk of GVHD can be reduced with exact HLA-type matching and the use of preventative drugs.

In an AUTO transplant, there is little risk of GVHD because the replacement stem cells are the patient’s own cells. However, there is a risk in an autologous transplant that some of the cells that are put back into the patient could still be cancerous.

Learn more by reading the Cancer.Net Feature series Understanding Bone Marrow and Stem Cell Transplantation.

Supportive therapies (symptom control)

Doctors often recommend supportive therapies for people with myeloma to reduce symptoms and complications. These may include:

• Erythropoietin, a red blood cell growth factor, may help patients with anemia.
  
  
• Antibiotics and intravenous immunoglobulins may treat or prevent infections.
  
  
• As mentioned above, bisphosphonates (drugs that increase bone density) help with bone pain and reduce the risk of fractures. These drugs also prevent high levels of calcium in the blood, which reduces the effects of having too much calcium circulating in the blood.
  
  
• Exercise is recommended to maintain bone strength and reduce the loss of calcium.
  
  
• Drinking an adequate amount of water and other healthy fluids can flush the kidneys and help them filter impurities from the blood.
  
  
• A balanced diet high in calories and protein helps prevent infection, as does getting plenty of rest and reducing stress.

To learn about the terms used in this section, read the Cancer.Net Feature: Cancer Terms to Know: During Treatment.

Clinical Trials Resources

Doctors and scientists are always looking for better ways to treat patients with multiple myeloma. A clinical trial is a way to test a new treatment to prove that it is safe, effective, and possibly better than a standard treatment. Patients who participate in clinical trials are among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.

Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that finding new drugs and other therapies is the only way to make progress in treating multiple myeloma. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with multiple myeloma.

To join a clinical trial, patients must complete a learning process known as informed consent. During informed consent, the doctor should list all of the patient's options, so the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different from the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment. Learn more about clinical trials, including patient safety, phases of a clinical trial, deciding to participate in a clinical trial, questions to ask the research team, and links to find cancer clinical trials.

Side Effects

Cancer and its treatment can cause a variety of side effects. However, doctors have made major strides in recent years in reducing pain, nausea and vomiting, and other physical side effects of cancer treatments. Many treatments used today are less intensive but as effective as treatments used in the past. Doctors also have many ways to provide relief to patients when such side effects do occur.

Fear of treatment side effects is common after a diagnosis of cancer, but it may be helpful to know that preventing and controlling side effects is a major focus of your child’s health-care team. Before treatment begins, talk with your child’s doctor about possible side effects of the specific treatments your child will be receiving. The specific side effects that can occur depend on a variety of factors, including the type of cancer, its location, the individual treatment plan (including the length and dosage of treatment), and the person’s overall health.

Ask your doctor which side effects are most likely to happen (and which are not), when side effects are likely to occur, and how they will be addressed by the health-care team if they do happen. Also, be sure to communicate with your doctor about side effects your child experiences during and after treatment. For more information on the most common side effects of cancer and different treatments, along with ways to prevent or control them, visit Cancer.Net’s section on Managing Side Effects, based on ASCO’s curriculum.

In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Learn more about the importance of addressing these needs in Cancer.Net’s section on Caring for the Whole Patient.

For more information on late effects or long-term side effects, please read the After Treatment section or talk with your doctor.

After Treatment

After treatment for multiple myeloma ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests during the coming months and years.

After successful control of the cancer with treatment, people with myeloma should have regular check-ups to watch for any reappearance of cancer. Maintenance therapy may be recommended to prevent recurrence of cancer for a year or longer. All patients requiring treatment for systemic myeloma are also treated with intravenous monthly bisphosphonates; however, the development of kidney dysfunction or osteonecrosis (a small area of dead bone) of the jaw in a small fraction of patients after chronic use may modify recommendations for bisphosphonate use in the future (see Treatment).

People treated for multiple myeloma are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about Healthy Living After Cancer.

To learn about the terms used in this section, read the Cancer.Net Feature: Cancer Terms to Know: After Treatment.

Current Research

Research for multiple myeloma is ongoing. The following advances may still be under investigation in clinical trials and may not be approved or available at this time. Always discuss all diagnostic and treatment options with your doctor.

Expanded use of stem cell transplantation. While autologous (AUTO) stem cell transplantation with high-dose chemotherapy is a standard treatment for myeloma, researchers are studying the benefits of tandem (double) AUTO transplantations, allogeneic transplantations, and tandem auto mini-allogeneic transplantations. Autologous means the stem cells are from the patient, and allogeneic means that the stem cells came from a donor. (For more information on transplantation, read the Treatment section)

New drugs. Rapid progress is being made in the treatment of myeloma. Several new drugs are being studied for the treatment of myeloma:

• Heat shock protein (HSP) inhibitors, also called stress proteins, are present in all cells to help them respond to environmental stresses, such as underheating or overheating. HSPs are overexpressed in the cells of certain cancer types and targeting them directly may help in the treatment of myeloma.
  
  
• Anti-angiogenesis inhibitors are drugs that block the action of a protein called vascular endothelial growth factor (VEGF) and are being tested in people with myeloma. VEGF promotes angiogenesis (the formation of new blood vessels), which is necessary for tumor growth and metastasis.
  
  
• The fibroblast growth factor receptor 3 (FGFR3) is expressed in approximately 15% of patients with myeloma and is involved in mitogenesis (cell growth), angiogenesis, and wound healing. Drugs that inhibit FGFR3 are being developed to help control cancer in these patients.
  
  
• p38 MAP kinase inhibitors block the production of cytokines (proteins produced by white blood cells that act as chemical messengers between cells), such as interleukin-6 and VEGF, in the bone marrow.
  
  
• Doxil (doxorubicin liposome injection) is a new way of delivering chemotherapy.

Myeloma represents a new treatment paradigm (a set of assumptions and practices) in cancer because the new drugs that target the tumor cell, tumor-bone marrow interaction, and bone marrow environment can overcome conventional drug resistance. Drugs are first tested in patients with advanced myeloma and then used to treat patients with earlier stage myeloma.

Drug combinations. Most myeloma cells will eventually become resistant to standard chemotherapy, a condition called multidrug resistance. New drugs and combinations of approved drugs are being researched to provide more options for patients with myeloma. One such combination is thalidomide, bortezomib, and dexamethasone. Another combination is bortezomib and lenalidomide. In May 2007, the FDA approved the combination treatment of bortezomib and doxil in people with myeloma whose disease has not responded to at least one other treatment.

Immunotherapy. This therapy, also called biologic therapy, helps to boost a person's immune system to fight cancer. It uses materials made either by the body or in a laboratory to bolster, target, or restore immune system function. Vaccines are a type of immunotherapy being explored in the treatment of multiple myeloma.

For more information on clinical trials specific to multiple myeloma, see the Multiple Myeloma Research Foundation's Clinical Trials Monitor.

Myeloma represents a new treatment paradigm (a set of assumptions and practices) in cancer because novel agents targeting the tumor cell, tumor-bone marrow interaction, and bone marrow environment can overcome conventional drug resistance. Drugs are first tested in patients with advanced myeloma and then used to treat patients with myeloma earlier in their disease course.

Drug combinations. Most myeloma cells will eventually become resistant to standard chemotherapeutic drugs, a condition called multidrug resistance. New drugs and combinations of approved drugs are being researched to provide more options for patients with myeloma. One such combination is thalidomide, bortezomib, and dexamethasone. Another combination is bortezomib and lenalidomide. In May 2007, the FDA approved the combination treatment of bortezomib and doxil in people with myeloma that has not responded to at least one other treatment.

Immunotherapy. This therapy, also called biologic therapy, helps to boost a person's immune system to fight cancer. Vaccines are a type of immunotherapy being explored in the treatment of multiple myeloma.

For more information on clinical trials specific to multiple myeloma, see the Multiple Myeloma Research Foundation's Clinical Trials Monitor.

Questions to Ask the Doctor

Regular communication with your doctor is important in making informed decisions about your health care. Consider asking the following questions of your doctor:

• Can you explain my pathology report to me?
  
  
• What stage is the myeloma?
  
  
• Am I symptomatic or asymptomatic? What does this mean?
  
  
• Is my kidney function being affected?
  
  
• What are my treatment options?
  
  
• What treatment do you recommend? Why?
  
  
• What are the goals of this treatment?
  
  
• What clinical trials are open to me?
  
  
• What are the possible side effects of this treatment, both in the short term and long term?
  
  
• How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?
  
  
• What follow-up tests will I need, and how often will I need them?
  
  
• What support services are available to me? To my family?
  
  
• Where can I get more information?

Patient Information Resources

International Myeloma Foundation
12650 Riverside Dr., Ste. 206
North Hollywood, CA  91607
Toll Free: 800-452-2873
Phone: 818-487-7455
www.myeloma.org

The Leukemia and Lymphoma Society
1311 Mamaroneck Ave.
White Plains, NY  10605
Toll Free: 800-955-4LSA (4572)
Phone: 914-949-5213
www.leukemia-lymphoma.org

Multiple Myeloma Research Foundation
383 Main Ave., 5th Floor
Norwalk, CT  06851
Phone: 203-229-0464
www.multiplemyeloma.org

American Society for Blood and Marrow Transplantation
85 W Algonquin Rd., Ste. 550
Arlington Heights, IL  60005
Phone: 847-427-0224
www.asbmt.org

Blood and Marrow Transplant Information Network
2310 Skokie Valley Rd., Ste. 104
Highland Park, IL  60035
Toll Free: 888-597-7674
Phone: 847-433-3313
www.bmtnews.org

National Bone Marrow Transplant Link
20411 W 12 Mile Rd., Ste. 108
Southfield, MI  48076
Toll Free: 800-LINK-BMT (800-546-5268)
Phone : 248-358-1886
www.nbmtlink.org

National Marrow Donor Program
3001 Broadway St., NE, Ste. 500
Minneapolis, MN  55413-1753
Toll Free: 800-MARROW2 (800-627-7692)
Office of Patient Advocacy: 888-999-6743
www.marrow.org

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