Treatment for multiple myeloma

Friday 30 November, 2007

Reviewed: Prof. Miles Prince MBBS (Hons) MD MRACMA FRACP FRCPA, Chair, Clinical Cancer Services; Professor, University of Melbourne; Director, Centre For Blood Cell Therapies, Peter Mac

On this page: ChemotherapySteroidsRadiotherapyThalidomideBortezomibImmunotherapy with interferonStem cell (or bone marrow) transplantationSurgery to strengthen bonePlasma exchangePrognosis


Multiple myeloma can be treated by chemotherapy, steroids, radiotherapy, thalidomide or thalidomide-related drugs, bortezomib and immunotherapy. Your doctor may recommend stem cell transplantation. Treatment with bisphosphonates and surgery can strengthen weak bones. Some people need plasma exchange. The choice of treatment depends on your age, your wishes and the stage of your cancer.

If your multiple myeloma is detected early, you may not need treatment. Your disease may remain stable. But you will need regular blood and urine tests.

If treatment is recommended, it is best to discuss the treatment options with your doctor. It may be comforting to have a friend or relative with you when talking to the doctor. It may also be helpful to make a list of questions to discuss with your doctor (see link for suggestions from this site).

Chemotherapy

Chemotherapy is the use of anti-cancer drugs. The aim is to destroy all cancer cells while doing the least possible damage to normal cells. The drugs work by stopping the cancer cells from growing and reproducing.

Different types of drugs are used. Chemotherapy may be taken as tablets or by injection into a vein (intravenous treatment).

Some people with multiple myeloma may have chemotherapy over many months or even several years. During the treatment, regular blood and urine tests will be done to see if the levels of M-protein are falling, which means the treatment is working.

Side effects of chemotherapy

Some drugs used in chemotherapy can cause side effects. They may include nausea (feeling sick), vomiting, feeling unwell and tired, and some thinning or loss of hair from your body and head. These side effects are temporary, and steps can be taken to prevent or reduce them.

Steroids

Steroids are often added to chemotherapy to help it work. Steroids are made in the body, but they can also be made artificially and used as treatment for diseases such as multiple myeloma. Steroids can cause swelling, increased appetite, increased energy, sleeplessness, muscle weakness, increased risk of infection and indigestion. The treatment can aggravate diabetes. Tell your doctor if you have any stomach pains while taking steroids. 

Radiotherapy

Radiotherapy treats cancer by using x-rays to kill cancer cells. These x-rays can be targeted to cancer sites in your body. Treatment is carefully planned to do as little harm as possible to your normal body tissues.

To be sure that the same area is treated each time, the radiation therapist will make some marks on your skin. These marks will be lines, crosses and dots applied with special inks. Sometimes, these non-permanent marks need to be redone during the course of the treatment.

Radiotherapy is very effective for the relief of bone pain caused by multiple myeloma, helps to prevent bone fractures, and may also relieve other conditions such as pressure on the spinal cord.

Side effects of radiotherapy

Radiotherapy can cause temporary side effects including nausea (which can be helped by medication), loss of appetite and tiredness.

Skin in the treatment area may become red and sore after two or three weeks of treatment. From the start of your treatment, you will need to take care when washing and avoid shaving the area or wearing clothing that rubs. Check with your doctor or nurse before using any soaps, talcs and lotions. Ask a member of your radiotherapy treatment team for a cream to ease the burning sensation.

Thalidomide

Thalidomide is thought to work against multiple myeloma by slowing blood vessel growth around the abnormal plasma cells (anti-angiogenesis). This reduces the nutrients that the plasma cells need to grow. It also helps the immune system fight the multiple myeloma.

Thalidomide is usually for people whose multiple myeloma has returned after initial treatment. It is taken as tablets every evening and is often combined with steroids and continued indefinitely. It can be used in combination with chemotherapy. Recently, drugs derived from thalidomide have been developed that work differently in the body and cause different side effects (for example, lenalidomide). 

Side effects of thalidomide

Common side effects include constipation, drowsiness and numbness in the feet and hands, which tend to occur if you have thalidomide over a long time. Less common side effects include a rash, dizziness and a dry mouth. Thalidomide can increase the risk of deep venous thrombosis (blood clots in the veins). Your doctor may suggest you take a form of blood- thinning medication while on thalidomide.

Thalidomide can cause birth defects if you take it while you are pregnant. If you are prescribed thalidomide you will have to sign a form and have phone interviews to confirm that you understand this risk. Men and women must use effective contraception while taking the drug, if there is any risk of causing a pregnancy. 

Bortezomib

Bortezomib works against abnormally functioning proteins within the plasma cell. Abnormal processes in the cancer cell are repaired, allowing the plasma cells to die normally.

Bortezomib is usually for people whose multiple myeloma has returned after initial treatment. You will have it by injection twice a week, with steroids. This will continue for some months. Bortezomib can sometimes be combined with chemotherapy.   

Side effects of bortezomib

Common side effects include nausea, numbness in the feet and hands, fatigue and temporary lowering of the blood counts. Less common side effects include dizziness, unsteadiness or imbalance. It can increase the risk of developing shingles (a rash caused by the chickenpox virus).

Immunotherapy with interferon

Interferon is a protein that has anti-cancer effects. Given as a treatment in multiple myeloma, it helps suppress the multiple myeloma cells. 

People usually have it after they've finished their initial chemotherapy. It can delay needing further treatment. You usually have interferon three times a week by injection under the skin. You may have it for months or years.

Side effects of interferon treatment

Interferon can cause flu-like symptoms (fever, chills and sweats) one to two hours after the injection. Some people have the injection before they go to bed, so these symptoms do not interfere too much with day-to-day life. Other side effects include tiredness, loss of appetite and muscle pain.

Stem cell (or bone marrow) transplantation

This treatment may be advised if your disease comes back, does not respond to treatment or if there is a high risk of it coming back. It allows you to have higher doses of chemotherapy. This may control your disease for longer.

This treatment is not usually advised for older people. It can be exhausting and has significant risks. Your doctor will discuss with you whether the treatment is suitable for you.

Stem cells grow in bone marrow (the soft tissue inside bones). They are immature cells, from which essential new cells for the body grow. High doses of chemotherapy can damage stem cells. So if you need high dose chemotherapy, and your doctor thinks you're strong enough, this treatment can put healthy stem cells into your body after the chemotherapy.

Stem cells can be taken from blood (this is called peripheral stem cell transplantation) or directly from bone marrow (this is called bone marrow transplantation).

The stem cells will either come from you before your chemotherapy (autologous donor), or from a donor whose stem cells closely match yours (allogeneic donor).

You or the donor may have injections of a growth factor beforehand. This stimulates the bone marrow to produce large numbers of stem cells for collection.

You will have blood taken by syringe from a vein (usually in your arm) or from a small tube going through a vein in the neck or chest. The blood goes through a machine that spins the cells at very high speed. A computer is used to separate the stem cells, which are placed in a collection bag. This collection process is called apheresis. 

If your own stem cells are taken, the remaining blood cells are returned to your body. An anticoagulant prevents the blood clotting; it may cause tingling in your fingers. Let the nurse know if this happens and changes can be made.

Sometimes, stem cells are taken from the bone marrow in the hipbone or breastbone. This is done in an operating theatre under general anaesthetic.

The stem cells will be put in your body after your high dose chemotherapy. It's like a blood transfusion.

The cells find their way into the bone marrow, eventually resulting in normal blood cell numbers. This can take some time. While you are in hospital, you will have a range of treatments aimed to help the treatment work. Ask your doctor or nurse for information about the transplant you will be having.

Side effects of stem cell transplantation

While you are waiting for the treatment to work, you will be prone to infections. You may bruise and bleed more easily, and may become weak, with little energy. Other possible side effects include mouth infection and ulcers, nausea, vomiting, diarrhoea or bleeding from the bladder. Let your nurse and doctor know if you have any of these things so that they can be treated.

Some people who receive stem cells from a donor develop graft-versus-host disease (GVHD), where the donor cells ‘attack' the person's organs and tissues. Generally, when this happens, it causes mild symptoms, but sometimes GVHD can be a serious illness. Discuss the risks with your doctor if you are going to have an allogeneic transplant.

Bisphosphonates

Bisphosphonates are a treatment for hypercalcaemia and for long-term strengthening of the bones. You have them by injection into a vein or as tablets. Bisphosphonates help to keep the bones strong and reduce fractures and bone pain.

If you have bisphosphonates by injection, you may have symptoms of fever and your skin may be irritated where the needle went in. Taken orally, bisphosphonates can cause side effects such as nausea, vomiting, stomach pain and diarrhoea. There is a slightly increased risk of poor bone healing if you need a tooth extracted. You should speak to your doctor about dental care while taking bisphosphonates.

Surgery to strengthen bone

Surgery is sometimes used to help strengthen weak or thin bones. This involves using a plate, screws or pins to hold the bone together or support a weak section of the bone. You will have a general anaesthetic and stay in hospital.

After surgery to strengthen bone, you will be helped to start moving again. A physiotherapist will show you exercises that will help you to stay mobile and try to reduce the loss of calcium from the bone. You will also have painkillers after the surgery.

Plasma exchange

Rarely, when the M-protein level in the blood is high and interfering with blood circulation, plasma exchange can remove some plasma from the blood.

The blood is slowly taken by a needle from a vein in one arm and passed through a machine that spins off the M-protein. The blood is then returned to the body through a vein in the other arm.

This treatment takes a couple of hours and is carried out frequently (perhaps daily or once every two days for a week) until the M-protein level is lower.

Side effects of plasma exchange

There may be some bruising around the needles in your arms. You may feel lightheaded during the plasma exchange, or have tingling in your lips or fingers from the anticoagulant, which is mixed with the blood to help separate the plasma. If you have any of these side effects let the doctor or nurse know and changes can be made.

Prognosis

Multiple myeloma can be controlled in most cases. With this control, or remission, people usually return to a state of normal or near-normal health. This may last for months or years. If any relapse or repeat of symptoms occurs, you should see your doctor, as you may need further treatment.

Updated: 30 Nov, 2007