Updated 06 Mar 2019

Treatment aims

The main aims of treatment are to substantially reduce the effect of the myeloma and to bring you into remission (a period when cancer cells are at low level or can no longer be detected) for as long as possible, with the best possible quality of life.

If you have symptomatic myeloma you’ll normally start treatment immediately – depending on a number of factors. Treatment will involve a combination of chemotherapy (anti-cancer drugs), steroids, biological therapies (which support the body to control the cancer) and possibly a stem cell transplant.

People with smouldering/asymptomatic myeloma may not need treatment straight away but will have regular check-ups instead.

If you're not being actively treated, this is known as ‘watch and wait’ or ‘active surveillance’.

Read our information on watch and wait.

Clinical trials

Although the outcome for people with myeloma continues to improve, there is still a long way to go to improve treatments and quality of life for people with myeloma. So if there’s a clinical trial (research study) available, your consultant might recommend that you consider this.

For more information on clinical trials, download or order our booklet Your guide to clinical trials.

The stages of myeloma treatment

Myeloma is not usually considered a curable disease. Instead, it is a disease which shifts between phases of remission (when cancer cells are no longer detected or reduced) and relapse (when cancer cells have returned or increased). Phases of remission, sometimes called ‘plateau phases’ can vary considerably in length of time between different people. Usually, people respond well to first-line therapy, and this period tends to be when most people experience the longest remission.

Unfortunately, people with myeloma will usually relapse after this first period of remission, but when this is the case there will be other treatment options available to you. Treatment following a first relapse is called ‘second-line’ therapy, and the aim of this treatment is to achieve a second remission. These are the standard treatment options available, from first-line through to fifth-line therapy.

First-line therapy: remission induction

There are two stages involved in first-line therapy. The aim of the first phase of treatment is to remove as many of the myeloma cells as possible from your bone marrow.

This first stage is known as remission induction or just induction therapy, which involves a combination of chemotherapy, steroids and biological therapies.

Chemotherapy, steroids and biological therapies

Chemotherapy is directly toxic to cancer cells. Steroids are toxic to these cells too, but steroids can also increase the cancer-killing effects of other chemotherapies. Biological therapies aim to help the body itself to attack or control the growth of cancer cells.

The exact drug, dose and combination you’ll be offered will depend upon your general health and fitness and whether a stem cell transplant is part of your treatment plan.

In general, if you are fit enough and your healthcare team think it’s appropriate for you, you may have high doses of a drug or combination of drugs followed by a stem cell transplant. If the doctors think this treatment is too strong for you, you’ll have drugs in standard doses.

Treatment is usually given in cycles. Each cycle can last for three to five weeks, and one course of treatment can include four to six cycles. You will have time off treatment after your course has finished. Overall, remission induction may last four to six months.

The most common drugs prescribed are listed below. All are taken by mouth (orally), unless stated otherwise.

Chemotherapy

  • cyclophosphamide
  • melphalan (Alkeran®)
  • bortezomib (Velcade®) −injected under the skin (subcutaneously).

Biological therapies

  • thalidomide
  • lenalidomide (Revlimid®)
  • pomalidomide (Imnovid®).

Steroids

  • dexamethasone
  • prednisolone.

Other drugs may be suggested, in different combinations. The most common combination used in first-line therapy for people fit enough to tolerate it is VTD (Velcade-thalidomide-dexamethasone). Velcade is the trade name for bortezomib.

Less fit people will be offered VMP (Velcade-melphalan-prednisolone) or CTDa (cyclophosphamide-thalidomide-dexamethasone-attenuated). An ‘attenuated’ drug programme (regimen) means you will have the smallest effective dose. These drug combinations will not usually be followed by a stem cell transplant.

People with free light chain myeloma or kidney problems will usually be offered a different drug combination, often including bortezomib (Velcade) and dexamethasone.

Thalidomide and similar drugs

There is evidence that the drug thalidomide can affect the development of babies (foetuses) in the womb. Women who may be pregnant should not take any combination of drugs which includes thalidomide or similar drugs such as lenalidomide and pomalidomide. While you are taking these drugs, you must use condoms or another barrier method of contraception. This is important for men as well as women, as thalidomide is present in the sperm of men taking it.

To avoid any risk to unborn babies, if you're taking thalidomide or similar drugs, you shouldn’t donate blood and must make sure no one else has access to your medication.

Thalidomide, lenalidomide and pomalidomide all increase the likelihood of developing blood clots, where the blood thickens and can cause blockages in the blood vessels. So if you take these drugs you will also be given medication such as low molecular weight heparin (LMWH) or aspirin to thin your blood and reduce the risk of clotting. LMWH is injected daily under the skin and aspirin is taken as a tablet.

First-line therapy: consolidation therapy

If after your initial treatment the paraprotein has gone, it’s called a complete response. If you have a complete response, you’ll still be considered for further treatment or consolidation therapy. This is because without the consolidation, the myeloma may quickly come back.

Consolidation therapy tends to involve either a stem cell transplant or a further combination of drugs.

Stem cell transplant

A stem cell transplant (sometimes called a bone marrow transplant) aims to give you healthy stem cells, which then produce normal blood cells. There are two main types of stem cell transplant:

  • autologous or autograft – this uses your own stem cells
  • allogeneic or allograft – this uses donor stem cells and is a higher risk procedure.

People with myeloma typically have autologous transplants, not allogeneic ones. You might also hear an autologous transplant called an auto-SCT. Occasionally allogeneic stem cell transplants might be considered for fitter people with a particularly aggressive type of myeloma.

It’s likely that you’ll take melphalan (a chemotherapy drug used to slow the growth of cancer cells) before your stem cells are returned to your body. The melphalan removes any remaining myeloma cells and prepares your bone marrow to receive the stem cells. This is called conditioning.

For more information on stem cell transplants, download or order our booklet: The seven steps: blood stem cell and bone marrow transplants.

Relapsed and refractory myeloma

Relapsed myeloma

People who have myeloma will almost always experience a relapse. Relapse is the term used after someone has responded well to treatment but the condition has returned later. Your doctor may suggest the following drug combinations at different stages of your treatment:

Second-line therapy

Second-line therapy may involve:

  • bortezomib and dexamethasone
  • carfilzomib and dexamethasone
  • CTD (cyclophosphamide-thalidomide-dexamethasone)

Third-line therapy

Third-line therapy options are typically:

  • lenalidomide, ixazomib and dexamethasone
  • panobinostat, bortezomib and dexamethasone.

Fourth-line therapy

Daratumumab monotherapy (daratumumab taken on its own) is most likely to be used as fourth line therapy. Daratumumab is also being trialled in combination with other drugs.

Fifth-line therapy

Fifth-line therapy may involve:

  • pomalidomide and dexamethasone
  • panobinostat, bortezomib and dexamethasone
  • bendamustine and dexamethasone.

Other drugs combinations which may help bring people back into remission include DT-PACE (a combination of chemotherapy drugs, thalidomide and a steroid) and ESHAP (a combination of chemotherapy drugs with a steroid).

Refractory myeloma

If myeloma stops responding to treatment, this is called refractory disease. In this case your consultant might suggest you take part in a clinical trial.

Refractory myeloma can occur at any stage in myeloma, but it’s more difficult to treat if this happens in an earlier phase.

If you relapse following a stem cell transplant but were previously in remission for a minimum of 12 to 24 months, then a second autologous transplant (using your own stem cells) may be an option for you. This will not cure the myeloma, but it should hopefully lead to another stable and lengthy remission period.

If you don’t want to take part in a trial, your consultant will help you choose the best treatment based on which drugs you’ve already tried, your general condition, and your wishes. Bortezomib, lenalidomide and pomalidomide are all drugs which may be used in this situation, usually in combination with dexamethasone.

Managing treatment and side effects

Possible side effects from your treatment may include the following. You are unlikely to get them all, as some are linked to specific drugs:

  • an achy feeling
  • frequent watery poos (diarrhoea)
  • difficulty pooing (constipation)
  • extreme tiredness (fatigue)
  • difficulty sleeping (with steroids)
  • hair loss (alopecia)
  • infections
  • lack of red blood cells (anaemia) which can make you tired, breathless and pale
  • mouth sores
  • mood changes
  • feeling sick (nausea)
  • upset stomach and being sick (vomiting)
  • loss of feeling or pain in your legs or other parts of your body (neuropathy)
  • blood clots (thrombosis)
  • poor appetite and loss of taste
  • increased appetite (with steroids)
  • weight changes.

If you have any side effects, tell your healthcare team as there are ways they can help. They can offer supportive care such as anti-sickness drugs, blood transfusions, pain management, and advice on mouth care, diet and preventing infection. Or they may be able to suggest a change in your treatment if any side effects become unmanageable.

Download our fact sheets on Understanding infection, Blood transfusions, Mucositis (sore mouth or gut) and Managing Sickness and Vomiting from our publications page.

For dietary advice for people with a weakened immune system, download or order our booklet, Eating well with neutropenia.

Managing the symptoms of myeloma

You may also experience symptoms which are related to the disease rather than the treatment. The following drugs may be used in this situation:

  • bisphosphonates to strengthen bones and reduce any pain resulting from bone damage
  • erythropoietin (EPO) injections to treat anaemia (this will increase your red blood count and stop you feeling tired and breathless)
  • erythropoietin (EPO) injections to treat anaemia (this will increase your red blood count and stop you feeling tired and breathless)
  • granulocyte-colony stimulating factor (G-CSF) to trigger the production of white blood cells to protect against infection
  • antibiotics to help prevent or treat infections
  • painkillers to help relieve bone pain.

Make sure your healthcare team are aware of all your symptoms, so you can get the right help.

Treatment for bone damage

Sometimes myeloma can cause damage to vertebrae, which are the bones making up your spine. You will have already been given bisphosphonate drugs to reduce the pain and increase the strength of your bones. You might also need an operation to repair the damaged bones to prevent the condition getting worse. If you need this operation you’ll be looked after by an orthopaedic surgeon, who’ll explain to you what’s involved.

Follow-up

Your follow-up will depend on what type of treatment, if any, you’re having, and how your condition has responded. If your illness has responded well, it may be some time before you need any further treatment.

Your consultant will explain how often you’ll come back for follow-up checks. These appointments are very important so do make sure you get to them.

The outlook

For most people, myeloma responds well to initial treatment but unfortunately it almost always comes back. There are many treatment options – all aiming for a period of time when there are no signs of myeloma (remission), or when the paraprotein or light chain levels in the blood are lower and stay lower (a plateau, or stable disease phase).

Your outlook is individual to you, so talk to your healthcare team, as they will have the fullest picture.

If you want to find out more

Cancer Research UK has more information on the general outlook for myeloma. Remember that statistics can only give an overall picture. Your own outlook is individual to you and will depend on your age, level of fitness and the stage of your disease. The Cancer Research UK information nurses can help you with any questions you may have about these statistics on 0800 800 4040.

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