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.