Let's Talk About Multiple Myeloma Treatment
Every case of this disease is different and so is every treatment plan. The choices can be a little complex, but this overview of potential options will help you get a clearer picture of the road ahead.
So you’ve got multiple myeloma (or maybe someone you know does). And you’re looking for the best way to fight back. A lot of what you read about this disease online can be discouraging, but our experts want you to know that things are not as bleak as they may seem. Prognosis has improved by leaps and bounds over the last several years, and doctors now have an armory of targeted medications at their fingertips. Although multiple myeloma (MM) isn’t considered curable, people are living longer—and better—than ever before.
Our Pro Panel
We went to some of the nation’s top experts in multiple myeloma to bring you the most up-to-date information possible.
Cindy Varga, M.D.
Medical Oncologist, Assistant Professor
Tufts Medical Center, Tufts University School of Medicine
Myo Htut, M.D.
Associate Clinical Professor of Hematology
City of Hope Comprehensive Cancer Center
Rebecca Silbermann, M.D.
Assistant Professor of Hematology/Medical Oncology
Oregon Health & Science University School of Medicine
Doctors don’t know exactly what causes MM, but it likely comes down to DNA damage and chromosomal differences. Genes known as “oncogenes” trigger cell growth while “tumor suppressor genes” slow it down—there are differences in these genes in people with multiple myeloma. Normal human cells have 46 chromosomes, but MM cancer cells are often found to be either missing a part of one of chromosome or have mixed up chromosomes in which parts are switched out of their proper order.
Targeted drugs and immunotherapy medications are therapies that target certain proteins and receptors in cancer cells to slow growth or boost a person’s immune system to help it destroy those cells. New versions of these drugs are being discovered and tested regularly. Current targeted and immunotherapy drugs for MM include immunomodulatory agents (IMIDs), checkpoint inhibitors, monoclonal antibodies, proteasome inhibitors, immunosuppressants, interferons, and cellular immunotherapy using T cells.
No, it’s not considered curable...yet. But it is treatable. Many new treatments have been discovered in the last decade, and some doctors are starting to call it a “chronic” condition that can be managed successfully for years.
Chemo is widely used in MM because it can target myeloma cancer cells anywhere in the body. Although some medicines are in pill form, chemo is usually delivered directly into someone’s bloodstream through an IV “infusion” or injection at a clinic or doctor’s office.
What Is Multiple Myeloma Again?
Multiple myeloma (MM) is a rare blood cancer involving tumors in the bone marrow, sometimes in more than one spot. As these tumors take up more and more space inside the bones, they keep healthy bone marrow from doing its job of making infection-fighting white blood cells and red blood cells, which carry oxygen around the body.
The average American’s risk of getting MM (also known as Kahler disease or plasma cell myeloma) at some point in their lifetime is just one in 132. About 30,000 cases of MM are diagnosed every year, and there are an estimated 130,000 people living with it in the U.S. today.
Like any cancer, MM is a serious condition. But people with the disease have a much brighter future today than they did even 10 years ago. Several new treatments have been approved in the last decade, and survival rates keep going up.
Today the percentage of people who live at least five years after diagnosis is over 50%. For people who are diagnosed at early stages of MM, the outlook is even better—the 5-year survival rate is over 70%.
Early-Stage Multiple Myeloma and Treatment
If your multiple myeloma is caught at its earliest stage—known as smoldering multiple myeloma (SMM)—you probably won’t need treatment. SMM is considered a precancerous condition, often detected when your doctor spots something abnormal on a blood test you’re getting for unrelated reasons. Most people with SMM don’t go on to get full-blown MM (experts aren’t sure why). If you have SMM, your doctor will most likely prescribe “watchful waiting,” including regular blood tests and other screenings to monitor the disease and see if it is progressing.
Treatment for Stages I, II, and III Multiple Myeloma
If your multiple myeloma is more advanced, you will need treatment to remove the cancer and/or help prevent it from progressing. There are several different strategies your cancer care team will look at. The first one is likely chemo.
Chemotherapy for Multiple Myeloma
Chemotherapy drugs kill cancer cells. It’s widely used in MM because it can target multiple myeloma anywhere in the body. Although some chemo medicines can be given in pill form, chemo is often delivered directly into someone’s bloodstream through an IV “infusion” or injection at a clinic or doctor’s office.
Chemo doses are given in cycles of a few weeks at a time so that you are able to rest and recover from each treatment before having another. The length of time you will need chemotherapy treatments for can vary, but it often lasts anywhere from four to six months.
Depending on the progression of the disease and any other treatments your doctor has planned for you, you may get chemotherapy in three different stages:
Induction chemotherapy: This combo of chemo and other drugs is given at the same time to kill as many cancer cells as possible. This stage of chemotherapy can last several months.
Consolidation chemotherapy: This cycle of chemo is given to people who’ve had a bone marrow or stem cell transplant. It’s a shorter course of treatment and basically acts as a “booster” to the first.
Maintenance chemotherapy: Usually, this involves a low dose of medication over a long period of time, meant to prevent relapse.
Common Multiple Myeloma Chemotherapy Drugs
There are many different chemotherapy medications used to fight multiple myeloma. Which ones your doctor recommends—and at what dosages—will depend on characteristics of your particular cancer cells, the severity of your symptoms, and your age.
More-intensive chemo treatment is often used in younger patients, and in those who are planning on going on to have bone marrow transplants. Chemo drugs can be used by themselves or in combination with other chemotherapy medications. Some chemotherapy medications used in treating MM include:
Adriamycin, Doxil (doxorubicin)
Cytoxan, Neosar (cyclophosphamide)
Toposar, VePesid (etoposide)
Side Effects of Chemotherapy
You probably have heard that chemotherapy can cause unpleasant side effects. And it can, it’s true. That said, other new medications can be prescribed at the same time to help you feel better and make treatment easier. Some side effects of chemotherapy may include:
Cholesterol and blood sugar increase
Diarrhea or constipation
Fertility issues. Some chemo drugs can cause younger women to go into premature menopause or become infertile. Women who want to have kids after treatment may choose to freeze their eggs before starting chemo.
Nerve and other damage. Certain chemotherapy medications can damage your nerves, causing tingling and numbness. Some drugs—especially if used for long periods of time—can damage heart cells.
Skin rash or hives
Other Medications for Multiple Myeloma
Since there’s no solid tumor a surgeon can go in and remove, medications are the crux of treatment for multiple myeloma. The armory of effective drugs is constantly increasing, and it’s common for someone with MM to be given combinations of two, three, even four or more medications at one time, to target multiple pathways of the disease. Bone-strengthening drugs, for example, help prevent fractures, while targeted therapy attacks specific proteins inside cancer cells.
The exact combination of medications depends on the stage of your disease, genetic and molecular differences in the cancer cells themselves, your age, and which drugs you tolerate best. Over time, you may need to switch medications more than once—moving from one combo of medications to another in order to keep the disease from progressing.
Targeted medications—sometimes called “novel” therapies—are medications that target very specific proteins or genes in your cancer cells to limit growth. Your doctor will run DNA tests and other tests on your cancer cells to figure out which targets to go after. Unlike chemotherapy, these targeted medications generally don’t cause a lot of harm to healthy cells and tissues. Some types of targeted medications used in treating MM include:
Histone deacetylase inhibitors (Panobinostat)
Monoclonal antibodies (Elotuzumab, Daratumumab)
Proteasome inhibitors (Bortezomib, Carfilzomib, Ixazomib)
Side Effects of Targeted Therapy
Side effects are different depending on the drug, but may include:
Diarrhea or constipation
Higher risk of infections
Tingling in limbs (peripheral neuropathy)
How Does Immunotherapy for Multiple Myeloma Work?
Immunotherapy medications—also called “biologics”—prime your immune system to fight the cancer on its own. They also starve the cancer cells of the blood they need to keep growing. Some immunotherapies used in treating MM include:
Pomalyst (pomalidomide) Panobinostat (histone deacetylase inhibitor)
Synovir, Thalomid (thalidomide)
Side Effects of Immunotherapy
Side effects are different depending on the drug, but some may include:
Diarrhea, abdominal pain
What Role Do Corticosteroids Play?
Corticosteroids reduce inflammation, swelling, and pain, and may also help with chemotherapy side effects like nausea and vomiting. They’re commonly prescribed as part of the “drug cocktail” for people with MM. The most common ones used in multiple myeloma are prednisone and dexamethasone.
Side Effects of Corticosteroids
Most corticosteroid side effects are temporary, and some people handle these drugs better than others. They include:
High blood sugar
If taken for many years, corticosteroids may lead to Cushing syndrome, a metabolic disease that can cause diabetes, fatigue, and other issues.
How Are Bone-Strengthening Medicines Used?
Because multiple myeloma can weaken bones, some people are given bone-strengthening drugs for up to two years to help slow down the bone damage and reduce bone pain and the risk of fractures. The two approved types are:
Bisphosphonates: This include the drugs Aredia (pamidronate) and Zometa (zoledronic acid)
RANK ligand inhibitor: This is commonly prescribed as Prolia (denosumab)
Side Effects of Bone Medicines
Bone-strengthening medications can cause:
In rare cases: unexplained jaw infections, tooth loss, and bone loss
Radiation for Multiple Myeloma Treatment
External beam radiation treatments use high-energy x-rays to kill cancer cells and help lower the chances that the cancer will come back. Radiation isn’t used in all MM cases, but when it is, it’s done through a type of x-ray machine that points a beam of radiation at the area where cancer is concentrated. Treatments are given frequently (sometimes daily) and tend to last for several weeks.
While some people have few if any side effects from radiation treatment, others have a tougher time of it. Also, side effects can show up immediately, or weeks or months after treatment. They usually go away, but some can stick around. The most common side effects are redness, blistering, or peeling of skin in the area being treated, plus nausea, diarrhea, and fatigue.
Multiple Myeloma and Bone Marrow Transplant
Bone marrow transplant (also called stem cell transplant), coupled with high-dose chemotherapy, is a treatment for multiple myeloma that’s often used in younger patients and those with an aggressive form of the disease.
Here’s how it works:
Stem cells called hematopoietic cells live in the bone marrow and make all of your blood cells.
In a bone marrow transplant, healthy hematopoietic cells are collected from either you or a donor and given to you through an IV.
They travel to the bone marrow and grow into healthy red and white blood cells and platelets.
When your own cells are transplanted, it’s called an autologous transplantation; if the cells come from a donor (usually a sibling), that’s called an allogeneic transplantation.
Bone marrow transplants tend to cause fairly severe side effects similar to those experienced with chemotherapy. Bleeding and serious infections can also happen.
The most dangerous complication can happen in allogeneic transplants of donor stem cells. It’s called graft-versus-host disease (GVHD) and is a condition where the donor immune cells start to attack the recipient’s tissues. GVHD is treatable but potentially deadly.
What About Clinical Trials?
Among the many challenges of multiple myeloma is the fact that over time, it tends to become resistant to your current treatment, whatever it may be. That’s why you’re likely to use several different combinations of medications over the course of your MM journey. New drugs and therapies are being investigated constantly—if your MM has become resistant to several lines of treatment, ask your doctor about current clinical trials.
Multiple myeloma treatment can be daunting and the terminology is sometimes confusing. If you don’t understand thoroughly the options your medical care team suggests, ask them to explain it again, in simpler terms. It may also be useful to enlist the help of a friend or loved one to go to appointments with you at first. Along with lending emotional support (we can all use some of that!), your appointment buddy can take detailed notes and write down questions for you to ask next time.
No one is saying going through multiple myeloma treatment is easy. The most important thing is that there is treatment, and you do have options when it comes to your health.
Multiple Myeloma and Prognosis: Multiple Myeloma Research Foundation (MMRF). (2020). “Multiple Myeloma Prognosis.” themmrf.org/multiple-myeloma/prognosis/
Multiple Myeloma and Early Stages: American Society of Clinical Oncology. (2018). “Multiple Myeloma: Types of Treatment.” cancer.net/cancer-types/multiple-myeloma/types-treatment
Multiple Myeloma and Chemotherapy: American Society of Clinical Oncology. (2018). “Multiple Myeloma: Types of Treatment.” cancer.net/cancer-types/multiple-myeloma/types-treatment
Multiple Myeloma and Other Medications: Medscape. (2019). “Multiple Myeloma Treatment Protocols.” emedicine.medscape.com/article/2006866-overview
Multiple Myeloma and Radiation: American Cancer Society. (2020). “Radiation Therapy for Multiple Myeloma.” cancer.org/cancer/multiple-myeloma/treating/radiation.html
Multiple Myeloma and Bone Marrow Transplant: American Cancer Society. (2020). “Stem Cell Transplant for Multiple Myeloma.” cancer.org/cancer/multiple-myeloma/treating/stem-cell-transplant.html