This is the third part of our series about the condition based on our patient booklet “Fast Facts for Patients and their Supporters: Myeloma”, which is freely available online. This article shows how you will be treated for myeloma as well as the treatment options if myeloma returns.

Although there is no cure for myeloma yet, modern treatments can control the disease for long periods. 1 in 3 patients now live for 10 years or more.

How Will I Be Treated?

If you have myeloma that is causing symptoms, you will be offered treatment.

The choice of initial treatment (also called induction therapy) will depend on:

• the myeloma stage
• genetic features
• your kidney function
• your general health.

Your doctor will discuss the options with you, so that you can make an informed decision about what is best for you. You may decide that you do not want to receive any treatment, in which case you can still receive supportive (palliative) care to control myeloma symptoms.

What Are the Options?

Initial therapy for myeloma usually consists of drug therapy to bring the disease under control (in other words, to induce remission). You may also be offered radiation treatment to control pain.

Depending on your general health and the nature of your myeloma, you may be offered further therapy (known as consolidation therapy), consisting of high-dose drugs and autologous stem cell transplantation (ASCT – you can find more details of this on pages 17 and 18). If your doctor feels that you are not suitable for ASCT, you may be offered further drug treatment to keep your symptoms under control.

The main types of drugs used in the treatment of myeloma are:

• chemotherapy drugs, which stop cancerous cells from dividing and reproducing
• biological therapies that target specific proteins inside or on the surface of cancer cells, blocking their growth and spread while limiting the damage to healthy cells
• steroids, which can help kill myeloma cells and increase the effects of chemotherapy or biological drugs.

A combination of drugs is usually given. 4–8 cycles of chemotherapy is usual. You will have a few days of treatment at a time with rest periods in between. You will normally be treated as an outpatient, although in some cases you may need to spend a short time in hospital.

What If I Have Other Medical Conditions?

Because myeloma mainly affects older people, many patients may have other medical conditions, such as heart trouble, diabetes, high blood pressure (hypertension) or lung disease. If this is true for you, you should be aware that these conditions may be affected by your myeloma or by the treatment used for this condition. For example:

• medicines used to treat myeloma can make blood pressure control and blood sugar control more difficult
• patients with lung problems may feel more fatigued or short of breath during therapy.

You can still live an active life with myeloma, despite these other medical problems, but you may need to see your doctor more often to make sure they are still well controlled.

Treatment When Myeloma Returns

Although current treatments for myeloma are very effective at inducing remission, there is no cure for the disease. This means that the disease will eventually return after a period of months or years (relapse).

Unfortunately, in some cases, myeloma may eventually develop to the point where it does not respond well to any of the standard treatments. This is called refractory myeloma. In this case, different combinations of drugs may be tried, or your doctor may suggest that you enter a clinical trial of a new treatment under investigation.

The following factors will determine what therapy you receive at any given point in time:

What Are the Treatment Options?

The choice of treatment will depend on a combination of these factors, and your doctor will discuss these with you.

• Depending on your original treatment, it may occasionally be possible to repeat this.
• You may be offered treatment with bortezomib, lenalidomide or thalidomide and steroids, often in some form of combination.
• You may be able to enter a clinical trial of a new drug or drug combination.
• In some cases, a second course of high-dose chemotherapy with autologous stem cell transplantation (ASCT) after another course of induction therapy may be possible.

Supportive Care for Myeloma

Specialist doctors and nurses are experienced in treating blood cancers like myeloma and will advise you on the best treatment for you.

Treatment of Symptoms

As well as treatment for the myeloma itself, you will also be offered treatment for the symptoms of the disease, to help you live as normal a life as possible. This supportive care will include:

• treatment of pain
• treatment of high calcium levels
• preventing or treating blood-related problems
• dealing with kidney problems.

Always remember the benefits of eating well and exercising.

Treatment of Pain

You will be given appropriate painkilling drugs. You will also be given a type of drug called a bisphosphonate, which strengthens weakened bone and reduces bone pain. Very severe bone pain or pain from spinal cord compression may also be treated by radiotherapy or surgery.

Treatment of High Calcium Levels

High levels of calcium in the blood can make you feel sick, drowsy, confused or unwell. Your doctor may advise you to drink plenty of fluids to help your kidneys remove the calcium from your blood. Bisphosphonate drugs may also be used to lower high calcium levels.

Preventing or Treating Blood-Related Problems

Tiredness

You may feel tired as a result of anemia caused by a reduced number of red blood cells in your blood. Your doctor may suggest a blood transfusion or, if you have kidney problems, anemia may be treated with a drug called erythropoietin, which is produced in the kidneys and increases the formation of red blood cells.

What you can do: Make a note of when you feel run down, how well you are sleeping and changes in your diet or physical activity that change how you feel. Discuss these with your doctor.

Risk of Infection

Because myeloma lowers white blood cell counts, making you more likely to get infections, your doctor may offer you drugs to prevent infections (prophylactic drugs), and may also advise you to have vaccinations, for example against flu.

What you can do: Don’t hide yourself away, but use your commonsense to minimize the risk of infection, including good hygiene practices.

Blood Clots

Myeloma also increases your risk of developing a blood clot (thrombosis), and your doctor may offer you drugs to prevent this. Also, in very rare cases, a build-up of paraprotein in the blood can make the blood become thicker than normal – this is called hyperviscosity. If this happens, you may need to undergo a procedure called plasmapheresis, which filters the excess paraprotein from the blood.

Dealing with Kidney Problems

If your kidneys are affected by myeloma, you may be given an infusion of fluids to help the kidneys clear the waste products out of your system. You will also be encouraged to drink plenty of fluids for the same reason and to avoid drugs that affect the kidney. Rarely, myeloma can cause the kidneys to stop working, in which case waste products will need to be removed from your blood by kidney dialysis.

End of Life Care

Although many people can live with myeloma for years, there may come a time when your diseases progresses to a point where you are likely to die from it. As always, your myeloma team will be there to offer you (and your family) support and to make you as comfortable as possible. You may also want to talk to a trained counsellor or minister of religion.

Please check out the other posts of our series here:

• What Is Myeloma, How Is It Diagnosed, Who Gets It, and Why?
• What Are the Types and Effects of Myeloma?
• Stem Cell Transplantation for Myeloma

Information based on Fast Facts for Patients and their Supporters: Myeloma (Karger, 2017).