Multiple Myeloma

Treatment

Mayo Clinic has played a leading role in developing new treatments for multiple myeloma. Although no cure exists, many effective treatments can prolong survival and greatly improve patients' quality of life.

For patients who have a stable form of myeloma called smoldering multiple myeloma, the hematologist may recommend no treatment. These patients are closely monitored for progression to multiple myeloma.

Patients whose multiple myeloma is not stable generally require immediate treatment. Initial treatment choices depend on the severity of the patient's condition (high-risk versus standard-risk based on the mSMART classification) and on eligibility for stem-cell transplantation. Transplant eligibility is determined by the patient's age and general health. Some patients may have the opportunity to participate in novel clinical trials.

Non-transplant Candidates

Patients who do not qualify for stem-cell transplantation are usually given combination chemotherapy with one of three commonly used regimens. These include:

• Melphalan, prednisone, thalidomide (MPT)
• Bortezomib (Velcade), melphalan, prednisone (VMP)
• Lenalidomide plus low-dose dexamethasone

The choice depends on the patient's clinical condition and risk status of the disease. Elderly patients, who may not tolerate these therapies, are often prescribed a different drug combination, such as melphalan and prednisone (MP).

Transplant Candidates

If a patient qualifies for bone-marrow transplant, the hematologist may recommend it as an initial treatment or suggest that other treatments be tried first. Recent studies have shown that survival may be similar whether transplantation occurs early (after initial chemotherapy) or is delayed and performed when the disease first returns (first relapse). The patient's needs and wishes are taken into account when choosing early versus delayed transplantation.

Whether transplantation is immediate or delayed, transplant candidates typically begin with four rounds of chemotherapy to kill cancer cells. Mayo Clinic avoids melphalan-based therapy in transplant candidates because it interferes with subsequent stem-cell collection. A recent landmark clinical trial at Mayo Clinic showed greatly improved patient response to chemotherapy consisting of lenalidomide combined with low-dose dexamethasone (Len/Dex). This regimen is favored for patients with standard-risk disease. Alternative chemotherapy treatments containing bortezomib are recommended for patients with high-risk myeloma and/or kidney failure.

During chemotherapy with drugs like thalidomide and lenalidomide, patients often are prescribed blood-thinning drugs to prevent clots, a side effect of treatment. The hematologist will also closely monitor the number of myeloma cells in the bone marrow and the amount of monoclonal protein in the blood and urine. This information helps track the patient's progress and enables the physician to adjust treatment as necessary. A decrease in monoclonal proteins usually means treatment is working, although M proteins rarely disappear completely from blood and urine.

After the initial chemotherapy treatments, stem cells are collected from the patient's bone marrow. Chemotherapy may then resume for patients who wish to delay transplantation.

Stem-Cell Transplantation

Stem-cell transplant, or autologous stem-cell therapy, involves transfusion of the patient's own immature blood cells to replace diseased or damaged marrow. Although stem-cell transplantation cannot cure myeloma, it can prolong survival.

Mayo Clinic routinely collects enough stem cells for two transplants in each eligible patient. Patients who do not respond fully to a first transplant may be offered a second. Patients who achieve a complete or very good response from an initial transplantation are observed or sometimes offered the option of a clinical trial investigating maintenance therapy. A second transplant is reserved as an option in case of relapse.

Treatment of High-Risk Myeloma

Mayo Clinic generally recommends novel therapies for patients with high-risk myeloma. Regimens containing bortezomib are favored initially, with the goal of achieving a complete response. Maintenance therapy is also often used to prevent an early relapse.

Treatment of Relapsed Myeloma

Almost all patients with myeloma eventually relapse. If relapse occurs more than six months after stopping therapy, the initial chemotherapy regimen is usually restarted. Transplantation may be recommended for patients who previously had stem cells collected and preserved.

The drugs recommended for relapse vary, depending on its severity. Because myeloma cannot be cured, patients with relapsed disease generally continue on one drug or regimen until relapse or adverse side effects, and then try the next option.

Mayo Clinic typically has numerous clinical trials with novel agents for patients whose disease has not responded to standard treatments. (See clinical trials.)

Treatment of Myeloma Complications

Patients may need surgery to repair broken or damaged bones. Medication such as pamidronate may be prescribed to prevent further bone damage. In patients who suffer bone pain and reduced height, a liquid plastic and/or an inflatable bone tamp may be injected into the skeleton (vertebroplasty or kyphoplasty). Pain relief is generally rapid and can be long-lasting. Patients whose spinal cords are compressed may be treated with steroids, radiation or, rarely, surgery.

Hypercalcemia (abnormally high blood-calcium levels) can be treated with hydration and steroids. Additional drugs may be prescribed to treat kidney damage and anemia or to prevent infections.

Supportive Care

Some people with multiple myeloma find physical training, physical medicine treatments and counseling helpful in coping with myeloma pain. With good treatment results, the patient usually can return to near-normal activity. Some restrictions, such as avoiding heavy lifting, may still be necessary.