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Multiple myeloma treatments

The information on this page was reviewed and approved by
Maurie Markman, MD, President, Medicine & Science at CTCA.

This page was updated on September 27, 2021.

Multiple myeloma treatment generally depends on the stage of the cancer, whether you are a candidate for a stem cell transplant, and other factors, such as personal preferences and needs.

Treatments for multiple myeloma include chemotherapy, targeted therapy, immunotherapies, steroids and, more rarely, radiation and surgery. These treatments are typically used in combination, and sometimes with the addition of a stem cell transplant.

Figuring out a treatment plan

If you’re diagnosed with multiple myeloma, several treatment types may be used depending on the disease progression and prognosis, or the chance of recovery.

The type of treatment your doctor recommends depends on three factors:

  • Type and stage of the cancer
  • Age and general health
  • Problems and symptoms the growths may be causing

Your treatment plan may have specific goals based on these factors. Goals may include removing the cancer, preventing additional damage from cancer, improving quality of life, relieving pain and other symptoms and side effects, or lowering the chance of recurrence.

Drugs

Drugs to treat multiple myeloma, which is a common treatment approach, include:

  • Proteasome inhibitors
  • Immunomodulatory drugs (IMiDs)
  • Steroids
  • Histone deacetylase (HDAC) inhibitors
  • Antibodies and chemotherapy

Patients diagnosed with multiple myeloma are commonly prescribed drugs such as corticosteroids, which may shrink plasma cell tumors. Steroids kill multiple myeloma cells directly and decrease inflammation, subduing some symptoms and side effects of other treatments. They include dexamethasone and prednisone and are usually used in combination with other drugs.

Chemotherapy

Chemotherapy for the treatment of multiple myeloma may consist of a single agent or a combination of drugs. Because each medication destroys tumor cells in different ways, giving several drugs together may make the cells more responsive to treatment. When treatment for patients with multiple myeloma involves chemotherapy, the drugs are typically given orally (by mouth, in pill form) or intravenously (by injection into the vein).

Many multiple myeloma patients receive chemotherapy in combination with other drugs or treatments to fight the disease and prevent recurrence. A typical multiple myeloma treatment plan may include:

  • Induction chemotherapy (a combination of drugs used to destroy as many myeloma cells as possible)
  • Consolidation chemotherapy (high doses of chemotherapy to destroy any remaining myeloma cells) followed by a single or tandem stem cell transplant treatment
  • Maintenance therapy (a less intensive course of chemotherapy to reduce the risk of recurrence)

Throughout your treatment, we will conduct routine blood tests and other diagnostic evaluations to check for myeloma cells and make modifications to your treatment plan as needed.

Chemotherapy drugs often used for multiple myeloma include:

  • Doxil® (liposomal doxorubicin)
  • Evomela® (melphalan)
  • Cytoxan® (cyclophosphamide)
  • VP-16 (etoposide)
  • Adriamycin® (doxorubicin)
  • Treanda® (bendamustine hydrochloride)
  • Oncovin® (vincristine)

Interventional radiology

Interventional radiology allows doctors to visualize tumors and perform real-time, image-guided interventional procedures. At Cancer Treatment Centers of America® (CTCA), we deliver treatment directly to tumors and perform image-guided bone marrow biopsies, lymph node biopsies, and vascular catheter and port placements. We may also provide palliative treatment and vascular access for stem cell transplantation.

Kyphoplasty is an example of a minimally invasive procedure used to relieve pain from compression fractures of the spinal vertebrae caused by multiple myeloma.

Radiation therapy

Radiation therapy for multiple myeloma may be used to treat a specific area where bone has been damaged and myeloma cells growing in the bone marrow are causing pain. Also, radiation therapy is sometimes given in preparation for a stem cell transplant, to destroy as many myeloma cells as possible.

Stem cell transplantation

A stem cell transplant may be used to treat multiple myeloma by infusing bone marrow with healthy cells, which helps stimulate new bone marrow growth and restore the immune system. Typically, patients with advanced-stage multiple myeloma who are younger than 70 and in otherwise good health are candidates for a stem cell transplant.

Before a stem cell transplant for multiple myeloma, you may undergo a preparative conditioning regimen, which involves intensive treatment to destroy as many myeloma cells as possible. You may receive high doses of chemotherapy and, in some cases, radiation therapy.

During the transplant, you receive the stem cells intravenously, much like a blood transfusion. The procedure takes about an hour. After entering the bloodstream, stem cells travel to the bone marrow and start to make new blood cells in a process known as engraftment.

In the months following the transplant, your care team will monitor your blood counts. You may need transfusions of red blood cells and platelets. Sometimes, the intensive treatments you receive before stem cell transplantation for multiple myeloma may cause side effects, including infection. In this case, your doctor may administer intravenous (IV) antibiotics.

If you had an allogeneic stem cell transplant (using donor cells), your doctor may prescribe certain drugs to reduce the risk of graft-versus-host disease, a condition in which the donated cells attack the patient’s tissues.

Targeted therapy

Targeted therapy drugs are designed to attach themselves to specific protein receptors in or on the surface of cancer cells. For patients with multiple myeloma, targeted therapy may be used alone or in combination with other treatments, such as chemotherapy or radiation therapy.

Monoclonal antibody therapy is a type of targeted therapy that may be used to treat multiple myeloma. These drugs are made of antibodies engineered in a laboratory. Once injected into the body, monoclonal antibodies may target specific proteins found on cancer cells, killing them or preventing them from growing.

Among the targeted therapy drugs that may be used to treat multiple myeloma are proteasome inhibitors. Proteasomes are enzymes inside cells that break down old proteins so they can be recycled into new proteins. This process is necessary to prevent a toxic build-up of proteins inside the cell. Proteasome inhibitors are designed to stop the proteasomes from recycling proteins inside cancer cells, causing a toxic protein overload that may kill the cell.

Some of these treatments may include:

  • Proteasome inhibitors are relatively new drugs used as the standard for all stages of multiple myeloma. They work by essentially stopping the body’s cells from taking out the garbage. The garbage (toxins) piles up and kills the cells. Because the cancer cells grow faster than other cells, they create more waste and die quicker when treated with proteasome inhibitors.
  • Histone deacetylase (HDAC) inhibitors are a new class of drugs that target proteins involved in cell multiplication and division. They’re often combined with a proteasome inhibitor and a steroid.
  • Selective inhibitors of nuclear export (SINE) drugs interfere with cellular processes that shuttle proteins from the cell’s nucleus, killing it.

Immunotherapy

Immunotherapy turns your immune system against cancer. These are usually drugs that make the immune system stronger or direct it to fight off the cancer cells.

  • Immunomodulatory drugs are a standard immunotherapy treatment for multiple myeloma. They activate immune cells, directly kill myeloma cells and prevent growth signals used by cancer cells.
  • Monoclonal antibodies are components of the immune system—antibodies—that tag specific proteins to be destroyed. They are produced naturally by your body but may also be introduced as an infusion to attack cells that express specific proteins.
  • Antibody-drug conjugates are antibodies bound to a drug. The antibody binds to the cancer cell, then delivers the drug to kill it.

Surgery

Though rare for multiple myeloma, surgery may be recommended to remove single tumors called plasmacytomas or tumors causing symptoms. Your doctor may also recommend radiation or other drug treatments after surgery.

Combination treatments

In most cases, multiple myeloma patients are prescribed a combination of treatments that work together for better end results and fewer side effects than any single treatment. These include:

High-dose chemotherapy with stem cell transplant

This treatment uses high doses of chemotherapy drugs to destroy the body’s blood cells, but it also damages healthy bone marrow cells in the process. Radiation may also be used to ensure all of the cancerous cells have been destroyed.

Those damaged cells are replaced with stem cells found in the blood (peripheral blood stem cells), through a stem cell transplant. These stem cells then repopulate the bone marrow, build the tissue back up and create new blood cells. The stem cells come from two possible sources:

  • Your own stem cells (autologous). Before undergoing chemotherapy, the patient’s stem cells are harvested. Because they’re from the patient, this procedure tends to have fewer complications. The vast majority of stem cell transplants are autologous.
  • Someone else’s stem cells (allogeneic): Stem cells are collected from a matched donor, usually a relative. Allogeneic transplants are used rarely because they carry more risk of complications—the donor cells may attack the body’s healthy cells too.

Drug combinations

Multiple drugs are usually combined to treat multiple myeloma. Instead of just one or two, your care team may recommend a custom combination of chemotherapy drugs, immunotherapy, targeted treatment and a steroid for personalized treatment options based on your test results, cancer stage, symptoms, co-occurring conditions, and other health information such as your age and general health.

Other treatment options

  • Watchful waiting involves waiting to see whether the disease progresses before taking action, especially used with smoldering multiple myeloma or if the condition is precancerous.
  • Clinical trials may be available. You may search through the National Cancer Institute database and ask your care team which ones may be right for you.

Supportive care services are also helpful in addressing side effects of treatment or the cancer itself, such as anemia, infections, blood clots, kidney failure, bone disease, pain or depression.

End-of-life and supportive care for patients with advanced multiple myeloma that hasn’t responded to treatment may include hospice care. In hospice, treatment is focused on improving the quality of the patient’s life, not extending lifespan. Hospice care focuses on pain relief and symptom management and may happen at home or in an inpatient facility.

CAR T-cell therapy

Chimeric antigen receptor T-cell therapy, or CAR T-cell therapy, is a cancer treatment that falls under immunotherapy. Immunotherapy is an approach to treating cancer that harnesses the power of your body’s immune system by using treatments that boost or improve the body’s defenses.

During CAR T-cell therapy, cells that naturally exist in your body, called T cells, are extracted from a blood sample and sent to a laboratory. There, scientists alter the DNA of these cells, giving them new receptors that latch on to myeloma cells. Then, these modified T cells are reintroduced into your blood, and they travel through the body locating cancer cells. By latching on to cancer cells, the new T cells improve your immune system’s ability to fight the cancer.

So for, one type of CAR T-cell therapy has been approved to treat multiple myeloma: Abecma® (idecabtagene vicleucel).

This treatment option alters T cells so that they attach to a protein called BCMA. The BCMA protein is located on the surface of myeloma cells. The altered T cells that latch on to this protein may boost the immune system’s ability to find and attack myeloma cells.

Abecma® is generally an option for myeloma patients who have exhausted other treatments. Most patients who receive this treatment have already undergone at least four other treatments.

The treatment starts with a procedure called leukapheresis, which involves two intravenous (IV) lines that remove blood from your body and circulate some of it back in. As blood leaves the body, it’s sent through a specialized machine that separates T cells from the blood. Then, the rest of the blood is delivered back to your body via the second IV line. The procedure may take two to three hours. You may be in a seated position or lying down during the process.

Once the collection of T cells has concluded, they’re transferred to a laboratory. The process of altering the T cells may take weeks to complete, so treatment doesn’t begin immediately after leukapheresis.

Before you’re able to start treatment, you’ll receive a short round of chemotherapy, lasting a couple of days. The chemotherapy equips the body to respond to CAR T-cell therapy.

Once the cells have been successfully altered and the chemotherapy is complete, the T cells are introduced into the bloodstream via a vein.

CAR T-cell therapy is a very specialized approach that requires expert knowledge. It’s important to receive treatment with CAR T-cell therapy under the supervision of doctors who have significant experience with this approach.

The potential side effects of this treatment may be severe and include:

  • Cytokine release syndrome (CRS): CAR T-cell therapy sometimes causes an overactive immune system, which may result in CRS. This tends to arise within days or weeks of the start of treatment. Mild symptoms of CRS may resemble the flu, but this condition may escalate.
  • Problems with the nervous system: CAR T-cell therapy may cause nervous system issues, which may show up as headaches, seizures, tremors and difficulty balancing.
  • Infections: The patient may experience more frequent infections due to a weakened immune system.

Clinical trials

Clinical trials provide an opportunity for cancer patients to gain access to novel cancer treatments that may prove to be more beneficial than standard treatments. For cancer treatment to continue to advance, clinical trials are essential, as they allow doctors to study new approaches and patients to benefit from new treatments.

Cancer Treatment Centers of America® (CTCA) runs many clinical trials for patients seeking innovative treatment options. Enrolling in a clinical trial may be beneficial for any person with cancer, but it’s an especially promising option for those who have exhausted standard-of-care approaches.

Before moving forward with a treatment plan, consider asking your doctor if enrolling in a clinical trial is a good option for you. Your doctor may be able to explain which clinical trials you may be eligible to join, how to join them, and what to expect.

Next topic: What are the facts about multiple myeloma?

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