Treatment options

Treatment and care of people with cancer is usually provided by a team of health professionals, both medical and allied health professionals, called a multidisciplinary team.

Treatment for myeloma depends on:

the type and stage of the disease
the presence and severity of symptoms
your general health.

Most people with myeloma are treated with a combination of drugs (usually 2 or 3). This is because different drugs are used to treat myeloma cells in different ways, and the combined effect helps treat as much of the disease as possible.

Treatment may involve the following:

Active monitoring^[11]^[12]

Depending on the type of myeloma you have, treatment may not be recommended straight away.

If your myeloma is in its early stages, you might have ‘active monitoring’ or “watchful waiting”. You will have regular check-ups with your doctor every 3–12 months. If there are signs that your myeloma is getting worse, your doctor will start treatment.

Chemotherapy^[11]^[13]

Chemotherapy is treatment that destroys cancer cells by stopping them from growing and dividing. Chemotherapy drugs that are commonly used to treat myeloma include melphalan, doxorubicin, cisplatin and cyclophosphamide.

Some side effects of chemotherapy include:

nausea
fatigue
hair loss
a drop in blood count If you develop a fever, you should contact your doctor or a member of your treating team as you may need early treatment for an infection.
a weakened immune system.

Most side effects of chemotherapy can be treatable and most will go away after treatment has finished.

Immunotherapy^[11]^[12]^[13]

Immunotherapy uses drugs to stimulate the immune system to attack cancer cells.

Immunomodulators are drugs that block the growth signal for cancer cells and boost the immune system to attack the cancer. They may be used in combination with chemotherapy for the treatment of myeloma. They may also be used when myeloma has come back (recurred).

The most common immunomodulators for myeloma are thalidomide, lenalidomide and pomalidomide.

Immunomodulators increase the risk of blood clots, so most people who take these drugs also take a blood thinner. While taking immunomodulators, women should not become pregnant and men should not conceive or donate sperm, as the foetus and sperm may develop abnormalities. Other side effects include:

pain
drowsiness
tingling hand and feet
nausea
low blood count
a weakened immune system.

Targeted therapy^[14]^[15]

Targeted therapy refers to treatment with drugs that are designed to specifically attack cancer cells without harming normal cells. These types of drugs affect the way that cancer cells grow, divide, repair themselves or interact with other cells.

Drugs used for targeted therapy of myeloma include bortezomib and carfilzomib, which are proteasome inhibitors. They may be used with chemotherapy to treat myeloma.

Proteasome inhibitors stop the breakdown of protein within myeloma cells. This causes the cells to stop growing and die.

These drugs may cause some side effects, but most can be managed. Possible side effects include:

fatigue
nausea
low blood counts
heart problems.

Other types of targeted therapy may include angiogenesis inhibitors (which stop the cancer growing new blood vessels) or HDAC inhibitors (which block the action of enzymes and may cause cell death).^[16]

Steroids^[14][17]

Steroids are usually given with chemotherapy, immunomodulators, proteasome inhibitors or other types of drugs.

Steroids (also called ‘corticosteroids’) are hormones naturally made in the body. They can also be made in a lab and used as drugs. The most common steroids used for myeloma are dexamethasone and prednisolone or prednisone.

Corticosteroids stop your immune system from causing inflammation in your body, and actively kill myeloma cells. They can also be used to help with nausea caused by chemotherapy.

Common side effects of steroids include:

mood changes
difficulty sleeping
increased appetite
fluid retention
weight gain
diabetes (if used for a long time).

If you are finding it difficult to cope with the side effects of steroids, talk to your doctor. They may be able to change the dose.

Stem cell transplant^[18]^[19]^[20]

If your myeloma is in its plateau phase (also called ‘remission’), you may be offered a stem cell transplant. This replaces damaged or destroyed blood stem cells in the bone marrow with healthy ones. These can be your own blood stem cells (called an autologous stem cell transplant) or from a donor (called an allogeneic stem cell transplant).

Stem cell transplants are not suitable for everyone. Treatment depends on:

the type of myeloma you have
how aggressive your myeloma is
how your myeloma responds to treatment
your age
your general health.

Some people continue to have drug therapies after a stem cell transplant.

Supportive treatment^[18]

You may also have treatment for the symptoms caused by myeloma. These do not target the myeloma itself.

The treatments may include:

antibiotics and antiviral drugs, to prevent infections
blood thinners, to prevent blood clots
bisphosphonates, to stop bone damage and reduce bone pain
radiation therapy, to reduce bone pain; this is usually done using focused X-ray beams
plasma exchange, to thin the blood by reducing the level of paraprotein.

Follow-up^[21]

After treatment, you might have regular visits to the doctor for blood tests, urine tests, bone marrow biopsies, X-rays or scans to check whether the cancer has come back (recurred).

If you notice any symptoms between appointments, tell your doctor as soon as possible.