Treating multiple myeloma

If you have multiple myeloma, you will be cared for by a team, which is usually led by a consultant haematologist who specialises in myeloma.

The team will discuss your condition and recommend the best treatment for you. However, the final decision will be yours.

Before visiting hospital to discuss your treatment options, it may be useful to write a list of questions to ask the specialist. For example, you may want to find out the advantages and disadvantages of a particular treatment.

There are two main aims in treating multiple myeloma:

• to bring the myeloma under control
• to prevent and treat problems associated with myeloma, such as Iron deficiency anaemia and bone pain

While treatment can often control myeloma and improve quality of life, myeloma usually can't be cured. This means additional treatment is needed when the cancer comes back (a relapse).

Not everyone diagnosed with myeloma will need immediate treatment if the condition is not causing any problems. This is sometimes referred to as asymptomatic, or smouldering myeloma .

If you don't need treatment, you will be monitored for signs the cancer is beginning to cause problems. If you do need treatment, the options outlined below are most commonly used.

Bringing myeloma undercontrol

The initial treatment for multiple myeloma may be either:

• non-intensive for older or less fit patients (this is more common)
• intensive for younger or fitter patients (thought to be too toxic for older or less fit patients)

The decision about which treatment is appropriate for you is usually based on your biological age or fitness.

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 non-intensive and intensive treatments involve taking a combination of anti-myeloma medicines. Intensive treatment involves much higher doses and is followed by a stem cell transplant.

The medicines usually include a chemotherapy medicine, a steroid medicine, and either thalidomide or bortezomib.

Chemotherapy

Chemotherapy medicines kill the myeloma cells. The most common types used to treat myeloma are melphalan and cyclophosphamide.

These treatments are mostly taken in tablet form. They are reasonably well tolerated and side effects are mild. Possible side effects include:

• increased risk of infections
• feeling sick
• vomiting
• hair loss

Your clinician will give you advice and information about your risk of developing potentially serious infections, andtell you what you can do to reduce your risk of picking up infections during your treatment.

Steroids

Steroid medications (corticosteroids) help destroy myeloma cells and make chemotherapy more effective.The two most common types used to treat myeloma are dexamethasone andprednisolone.

Steroids are taken orally (by mouth) after eating. Possible side effects include heartburn , indigestion , increased appetite, mood changes and problems falling asleep.

Thalidomide

Thalidomide can help kill myeloma cells. You takeit as a tablet every day, usuallyin the eveningas it can make you feel sleepy.

Other common side effects include:

• constipation
• dizziness
• rashes
• numbness or tingling in the hands and feet (peripheral neuropathy)

Thalidomide can cause birth defects, so it should not be taken by pregnant women, and a reliable form of contraception such as a condom must be used during treatment.

There is also a risk you may develop a blood clot when taking thalidomide, so you may be given medication to help prevent this. Contact your care team immediately if you develop symptoms of a blood clot, such as pain or swelling in one of your legs, or chest pain and breathlessness .

Bortezomib

Bortezomib (Velcade) can help kill myeloma cells by causing protein to build-up inside them.

There are some limitations as to who can have bortezomib, but a member of your care team will discuss this with you.

The medication is given by injection, usually under the skin.Possible side effects include:

• tiredness
• nausea
• diarrhoea
• numbness or tingling in your hands and feet (peripheral neuropathy)

Stem cell transplant

After initial therapy with primarily outpatient-based treatments, people receiving intensive treatment will be given a much higher dose of chemotherapy medication as an inpatient to potentially help destroy a larger number of myeloma cells. This aims to achieve a longer period of remission (where there is no sign of active disease in your body).

However, these high doses also affect healthy bone marrow, so a stem cell transplant will be needed to help your bone marrow recover.

In most cases, the stem cells will be collected from you before treatment (autologous transplantation). In rare cases, they are collected from a sibling or an unrelated donor.

Treating relapses

Further treatment is needed if myeloma returns. Treatment for relapses is generally similar to initial treatment, although non-intensive treatment is often preferred to further intensive treatment.

Additional medications such as lenalidomide, pomalidomide and other chemotherapy medicines may be added, or usedagain as your haematologist feels is appropriate.

You may also be asked if you want to participate in clinical trial research intonew treatments for multiple myeloma.

Lenalidomide and pomalidomide

Lenalidomide and pomalidomide are similar to thalidomide. They're both taken by mouth, and both canhave an effect on the cells produced by your bone marrow, which can cause:

• increased risk of infection asa result ofa low number of white blood cells
• anaemia caused bya low number of red blood cells
• bruising and bleeding because ofa low platelet count

They may also increase your risk of developing a blood clot and have other side effects similar to thalidomide.

Let your care team know if you experience any problems or unusual symptoms while taking lenalidomide or pomalidomide.

Treating symptoms and complications of myeloma

As well as the main treatments for multiple myeloma, you may also need treatment to help relieve some of the problems caused by the condition.

For example:

• painkillers may be given to reduce pain
• radiotherapy may be used to relieve bone painor help healing after a bone is surgically repaired
• bisphosphonate medication eithergiven as tablets or by injection, this mayhelp prevent bone damage and reduce the levels of calcium in your blood
• blood transfusions orerythropoietin medication may be usedto increase your red blood cell count andtreat anaemia
• surgery may be carried outto repair or strengthen damaged bones, or treat compression of the spinal cord (the main column of nerves running down the back)
• dialysis may berequired if you develop kidney failure
• plasma exchange treatment to remove and replace a blood component called plasma may be carried out if you have unusually thick blood (hyperviscosity)

These treatments can each cause side effects and complications, so make sure you discuss the potential risks and benefits with your treatment team beforehand.

Clinical trials and research

Research is ongoing to find new treatments for multiple myeloma and work out ways to improve the use of existing ones. To help with this, you may be asked to take part in a clinical trial during your treatment.

Clinical trials usually involve comparing a new treatment with an existing one to see whether the new treatment is more or less effective.

It's important to remember, however, that if you are given a new treatment, there is no guarantee it will be more effective than an existing treatment.

There will never be any pressure for you to take part in a trial if you do not want to.

Search clinical trials for multiple myeloma .