The stages of myeloma treatment
Myeloma is not usually considered a curable disease. Instead, it is a disease which shifts between phases of remission and relapse. These phases of remission, sometimes called ‘plateau phases’ can vary in length of time considerably between patients.
Usually, patients respond well to firstline therapy, and this period tends to be where most patients experience the greatest length of remission.
Unfortunately, patients will almost always 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 acheive a second remission. This information talks about the standard treatment options available, from first-line through to fourth-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 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 work to discourage the future growth of other cancer cells. The exact drug, dose and combination you’ll be offered will depend upon your general health, age, and whether you’ll have a stem cell transplant at a later date.
- Older or less fit patients tend to have standard doses
- Younger or fitter patients tend to have higher doses followed by a stem cell transplant.
Treatment is usually given in cycles – cycles of treatment can last for three to four weeks. You will have time off after your course has finished. One course of treatment can include four to six cycles. Overall, remission induction may last four to six months.
The most common drugs prescribed are listed below. All are taken orally, unless otherwise noted.
- melphalan (Alkeran™)
- bortezomib (Velcade™) (given subcutaneously-injected under the skin).
- lenalidomide (Revlimid™)
- pomalidomide (Imnovid™).
Other drugs may be suggested, in different combinations. The most common combination used in first-line therapy, especially for younger or fitter patients, is CTD (cyclophosphamide-thalidomide -dexamethasone).
Usually older or less fit patients will be offered CTDa, which stands for cyclophosphamide-thalidomidedexamethasone-attenuated. These are the same drugs used in CTD but using an ‘attenuated’ regimen, which means you have smaller doses. CTDa will not usually be followed by a stem cell transplant.
If you are taking any form of CTD you should be using a barrier method of contraception whilst on treatment. You are also advised not to donate blood or share medication.
The drug thalidomide (in CTD) has been associated with birth defects. So thalidomide, along with similar drugs like lenalidomide and pomalidomide, should not be taken by women trying to get pregnant.
CTD and CTDa aren’t always the first drugs of choice at remission induction stage. For example, patients with free light chain myeloma or patients with kidney problems will usually be offered another drug combination, often including bortezomib and dexamethasone.
First-line therapy: consolidation therapy
If after your initial treatment all the myeloma cells have gone, it’s called a complete response. If you have a complete response you’ll still need further treatment or consolidation therapy. This is because without the consolidation, the myeloma would quickly come back.
Consolidation therapy tends to involve either a stem cell transplant or a further combination of drugs. These consolidation treatment options are explained below:
Stem cell transplant
A stem cell transplant (sometimes called a bone marrow transplant) aims to give patients healthy stem cells, which then produce normal blood cells.
There are two main types of stem cell transplant:
- Autologous or autograft – this uses the patients’ 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 younger, fitter patients with a particularly aggressive type of myeloma.
With autogolous transplants, once you have a complete response after your initial treatment, stem cells will be collected from your blood using a special machine.
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 you can download our booklet: Seven steps: Blood stem cell and bone marrow transplants, or order it in print for free
Drugs to treat the symptoms of myeloma
You may also experience symptoms which are related to the disease, instead of the treatment. The following drugs may be used in this situation:
- Bisphosphonates to 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.
- 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 the bones. As well as this, 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.
As well as active treatment of your illness, you may also need care around things like prevention of infection, blood transfusions, mouth care, diet, pain management and dealing with complications of your illness or of your treatment.