Multiple Myeloma Treatment
If you are diagnosed with multiple myeloma, your doctor will discuss the best options to treat it. This depends on several factors, including the type and stage of the cancer and your general health.
Your treatment for multiple myeloma will be customized to your particular needs. One or more of the following therapies may be recommended to treat multiple myeloma or help relieve symptoms.
Watchful waiting
For patients with asymptomatic (smoldering) myeloma or monoclonal gammopathy of undetermined significance (MGUS), a watchful waiting approach may be appropriate. The watchful waiting approach involves closely monitoring multiple myeloma without active treatment.
Chemotherapy
Chemotherapy is the usual starting point in treating multiple myeloma. It uses special drugs that kill fast-growing cells, like multiple myeloma cells. MD Anderson offers the most up-to-date and advanced chemotherapy options.
Targeted therapy
MD Anderson is among just a few cancer centers in the nation that are able to offer targeted therapies for some types of multiple myeloma. Targeted therapy is a broad term used to describe drugs that specifically target weaknesses of the cancer cells. This can mean targeting the blood vessels that feed tumors or attacking specific genetic and proteins of cancer. Ultimately, by targeting the weaknesses of cancer, these treatments help stop its growth and spread.
Immunotherapy
Immunotherapy is one of several innovative targeted therapies performed by MDAnderson. It uses your own immune cells to fight off cancer cells. Usually, the immune system does not attack cancer cells because they produce special proteins that help them blend in with other cells. Immunotherapy drugs interfere with the production of these proteins, triggering an immune response to fight off your cancer. There are a few different methods used for immunotherapy, including:
- Monoclonal antibodies, including Darzalex (daratumumab) and Empliciti (elotuzumab)
- Chimeric antigen receptor (CAR) T cells, which are genetically modified T cells that fight the myeloma directly
- Bispecific t cell engagers, which help activate and get your own immune cells next to myeloma cells in your body to kill them
- Cytokine therapies
- Vaccine therapy
Radiation therapy
Radiation therapy often plays a valuable role in providing quick pain relief and decreasing the risk of fractured bones. It involves using a high-energy beam to quickly kill cancer cells in a specific area. Radiation therapy can help prevent nerve compressions by attacking soft tissue collections of myeloma cells (plasmacytomas). It is also useful for targeting plasma cell tumors present in one location (solitary plasmacytoma). In these situations, radiation therapy alone is often used as the primary treatment.
A typical radiation treatment plan for a patient with multiple myeloma includes five sessions a week for approximately two weeks. We use computed tomography (CT) scan based radiation planning, immobilization devices to minimize patient movement during treatment, and modern radiation planning techniques that permit focused radiation delivery. Our Radiation Oncology Center treats more than 100 multiple myeloma and plasmacytoma patients each year, with a team of four skilled radiation oncologists who specialize in the management of patients with hematologic malignancies. Our ultimate goal is to administer effective, safe, modern radiation therapy while limiting toxicity.
Stem cell transplants
A stem cell transplant (or bone marrow transplant) replaces defective or damaged bone marrow cells with your own healthy blood-forming cells. First, your doctor will remove some of your healthy, blood-forming stem cells. Then, you will receive high-dose chemotherapy to kill off the diseased bone marrow cells. Finally, your healthy blood-forming stem cells will be transplanted in place of the diseased tissue. If a stem cell transplant is needed, MD Anderson has one of the most active and advanced programs in the nation.
Plasma exchange
High levels of abnormal proteins can lead to thickening of the blood. The liquid component of your blood, called the plasma, can be removed and replaced with normal plasma from a healthy donor. This can quickly relieve symptoms of increased blood thickness (hyperviscosity) until chemotherapy/immunotherapy has a chance to destroy the multiple myeloma cells that produce the abnormal protein.
Learn more about multiple myeloma:
Your questions about BCMA and multiple myeloma, answered
You may have heard someone with multiple myeloma mention the possibility of BCMA-targeted therapy and wondered what BCMA means and why it is relevant in cancer treatments.
For answers to these questions and more, we spoke to , director of multiple myeloma clinical research at MD Anderson.?
What is BCMA?
BCMA stands for B cell maturation antigen, and it's emerged as an important target in multiple myeloma over the last five years or so. Even though myeloma is the second-most common blood cancer, it is considered a rare cancer ¡ª much rarer than solid tumors cancers such as colorectal cancer, breast cancer or lung cancer. And although there are fewer patients with this type of cancer, there have been several new drugs developed for multiple myeloma in recent years that have significantly improved patient outcomes.
What is BCMA a marker for?
BCMA is highly expressed ¡ª or highly shown ¡ª on the surface of myeloma cells. That makes it also a very attractive drug target, so there have been several clinical trials looking at drugs that target BCMA.
What drugs or therapies target BCMA??
There are a few drugs and therapies that target BCMA. The first is chimeric antigen receptor (CAR) T cell therapy, and there are now two FDA-approved BCMA CAR T therapies (idecabtagene vicleucel and ciltacabtagene autoleucel) available.? BCMA CAR T therapies have shown strong efficacy, and it is very nice for patients to potentially be off all treatment after receiving a single CAR T infusion. However, access to myeloma CAR T remains limited, and the time it takes for CAR T to be manufactured and ready to give to a patient reduces their role in patients in immediate need of treatment.?
The second is bispecific BCMA-directed CD3 T cell engager, which is a more conventional drug. These drugs, also called BCMA bispecifics, are ¡°off the shelf.¡± This means that there's no need to wait for the therapy; patients can get their treatment when they need it, right away. And so, the , teclistamab, in October 2022. There are several clinical trials for similar drugs across the United States and others in development, and all have shown unprecedented efficacy in relapsed and refractory multiple myeloma for an off-the-shelf product.
I use both for my patients, depending on their individual circumstances, and both are going to be very important for multiple myeloma therapy. Because bispecifics for myeloma are relatively new and require hospitalization for the first several doses to monitor for side effects, they are generally only available at more specialized cancer hospitals like MD Anderson. Hopefully, that will change in the future, and more myeloma patients will have access to bispecific drugs in the community as the familiarity and logistics of administration improve.
What sort of patients are offered BCMA therapy?
Patients with relapsed refractory multiple myeloma are good candidates for BCMA therapy. Currently, BCMA-targeted therapies with CAR T and bispecifics are approved for patients with at least four prior treatment regimens that have included the three main classes of myeloma therapies, including a proteasome inhibitor, an immunomodulatory agent and an anti-CD38 monoclonal antibody.
Historically, new drugs have had response rates of about 30% in patients with relapsed refractory multiple myeloma. This means about 30% of patients have some reduction in their myeloma levels. On the other hand, for the new BCMA drugs with bispecifics and CAR T, the response rates range from 60% to 90%.
Why is BCMA a good drug target?
BCMA has biological significance: it's important for B cell signaling and plasma cell persistence and growth, so it's typically expressed on the B cells and plasma cells.
We're always concerned about the on-target or off-target effects of different treatments, and so far, BCMA seems to be a fairly clean target. These drugs primarily target myeloma cells or plasma cells and leave other cells alone, which makes them attractive.??
What would you like patients to know about BCMA bispecifics?
BCMA bispecifics are a fairly new type of myeloma therapy, and we¡¯re offering them here at MD Anderson, along with clinical trials of new treatment options.?
One of those , which is a BCMA¡ÁCD3 bispecific antibody with encouraging efficacy and a manageable safety profile. We¡¯re the only site in Texas for the study, which has enrolled 252 patients around the world. I¡¯m presenting some interim results at the 2023 ?(ASCO) Annual Meeting. The highlights of our findings are that the optimal 200 mg dose produced high response rates that were deep and durable in patients whose myeloma was resistant to standard therapies.
What can patients expect in the future?
There are a lot of trials looking at bispecific antibodies in different contexts, including in different antigens or different targets, other than BCMA. They have shown a lot of promise in clinical trials, and we have several here at MD Anderson in our myeloma group that are ongoing or planned. There are also trials looking at using bispecific antibodies in earlier lines of therapy, where the patients aren¡¯t required to have tried four other treatment regimens before being prescribed one.?
This is just the beginning of immunotherapy in myeloma, and it will be a very important modality for treating patients moving forward. I tell my patients that even five years from now, treatments will be ahead of where they are today, and we are far ahead of where we were even a few years ago. I think that there have been very, very tangible improvements, not only for the survival of people with multiple myeloma but for their quality of life as well.
?or by calling 1-877-632-6789.
Autologous stem cell transplants: What to expect
Since they were first introduced more than 60 years ago, stem cell transplants have cured or extended the lives of millions diagnosed with aggressive lymphomas, leukemias, myelomas and other blood cancers.
One type of transplant, called an allogeneic transplant, uses stem cells from a donor. But in many cases, a transplant may use stem cells from a patient¡¯s own body. This is called an autologous stem cell transplant.
We talked with , to learn more about what happens when a patient becomes their own donor.
What are hematopoietic stem cells?
The immature, undeveloped cells that live in the bone marrow where blood is made are called hematopoietic stem cells. Hematopoietic means blood-forming. These ¡°baby¡± cells have not yet decided which type of blood cell they want to be when they grow up. Eventually, they¡¯ll mature into one of three types:
- white blood cells to fight infection
- red blood cells to carry oxygen throughout the body
- platelets to control bleeding
Who needs a stem cell transplant, and why?
Patients with blood cancers receive high doses of chemotherapy to wipe out cancer cells in the bone marrow. The powerful treatment kills not only cancer cells, but also healthy, blood-forming stem cells. These hematopoietic stem cells need replacing after the chemotherapy ends so the body can continue making blood.
What is an autologous stem cell transplant?
Some patients rely on healthy donors for stem cells. Others ¡°bank¡± their own stem cells, which will be transplanted back into their bone marrow after the high-dose chemotherapy treatment is complete. This type of transplant is called autologous. Auto means self.
Who is eligible for an autologous stem cell transplant?
Autologous stem cell transplants are an option for patients whose cancer is in remission or has stabilized. This type of transplant is used most frequently to treat multiple myeloma and lymphoma.
Leukemia patients usually receive an allogeneic stem cell transplant.? That¡¯s because research has shown that stem cells from donors help prevent leukemia from returning.
What are the steps in an autologous stem cell transplant?
- Collecting the stem cells: Before treatment begins, a needle is inserted into the patient¡¯s arm vein. Blood is withdrawn and redirected into a special machine that removes about 4 million stem cells ¨C the amount needed for a transplant. The stem cells are frozen until needed, and the rest of the blood is returned to the patient¡¯s body.?
- Conditioning: The patient receives high doses of chemotherapy to kill cancer cells and prepare, or ¡°condition,¡± the body for transplant. This typically takes one to seven days.
- Transplanting the stem cells: After conditioning is completed, the stem cells are thawed and reintroduced into the recipient¡¯s vein through an IV. The stem cells automatically migrate to the bone marrow. About two weeks later, they begin producing normal, cancer-free blood cells.
What happens after an autologous stem cell transplant?
Many transplant recipients agree that the several weeks following transplant are the most challenging. Their blood counts are still very low during this time. Infection risk is high due to lack of infection-fighting white blood cells. Patients may be anemic due to lack of red blood cells. They¡¯re also at risk for bleeding due to lack of platelets.
Doctors prescribe antibiotics to prevent infections, and patients will likely need transfusions of platelets and red blood cells. During this time, they¡¯ll still be experiencing side effects of the chemotherapy they received during conditioning. Side effects may include nausea, diarrhea, hair loss, mouth sores and fatigue.
Most autologous transplant patients see a steady return to normal blood counts within two to four weeks. They can usually return to their normal activities in three to six months.
What¡¯s the difference between a stem cell transplant and a bone marrow transplant?
In the early days, stem cells were collected directly from the bone marrow. Patients were taken to the operating room, anesthetized, and doctors inserted needles to remove bone marrow from the hip bone. Stem cells were extracted from the marrow and frozen until transplant day. This is where the term ¡°bone marrow transplant¡± originated.
Today, we use medications that stimulate the stem cells to move out of the bone marrow and into the bloodstream, where they can be collected more easily. Stem cell transplant is very similar to bone marrow transplant, except the stem cells are harvested from the patient¡¯s bloodstream rather than from the bone marrow.
What¡¯s the main advantage of an autologous stem cell transplant?
A successful autologous stem cell transplant helps many people with lymphoma or multiple myeloma become cancer-free or delays the cancer¡¯s return. Patients who use their own cells avoid graft vs. host disease, which occurs when the body views cells from a donor as foreign and attacks them.
Is one autologous stem cell transplant enough?
Most patients need only a single autologous transplant. Others, particularly those with multiple myeloma, may receive a planned second transplant several months after the first one. This is called a tandem transplant.
What¡¯s your advice for patients considering an autologous stem cell transplant?
Recovery is a slow process, so patience is required. Most patients go from feeling lousy the first month after transplant to feeling back to normal six months later.
But everybody¡¯s different. Some patients recover in three months, and some need a year to regain their strength and stamina. Take one day at a time, and you¡¯ll get through it. Your MD Anderson team is here to support you every step of the way.
or by calling 1-877-632-6789.
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6 facts about smoldering myeloma
Sometimes, routine health exams like blood tests can uncover health issues you didn¡¯t even know you had. That¡¯s often the case with a rare, pre-cancerous condition called smoldering myeloma.
¡°Abnormalities in routine blood work are the first red flag,¡± says myeloma specialist Patients will receive additional testing, and if results reveal a certain level of plasma cells in the bone marrow or an increase in abnormal protein in your blood, you may be diagnosed with smoldering myeloma.
¡°Most patients with smoldering myeloma don¡¯t have symptoms that can be directly attributed to the underlying blood disorder,¡± says Manasanch.
Abnormal plasma cells can turn into smoldering myeloma
Plasma cells are an important part of our immune system. They live in the bone marrow. Their main role is to produce antibodies to fight infection. Sometimes these cells divide too quickly and produce abnormal cells.
These abnormal cells can turn into multiple myeloma, a cancer of the bone marrow. But sometimes they may cause smoldering myeloma, named for the disease¡¯s likelihood to get worse over time.?
¡°It¡¯s what we call a precursor stage of multiple myeloma,¡± Manasanch says.
Risk factors for smoldering myeloma aren¡¯t clear
Because it¡¯s rare, it¡¯s not clear what causes certain people to develop smoldering myeloma. The disease is more common in men, Black people and individuals who have been exposed to chemicals, such as Agent Orange and benzene. It is also more common in people who have had family members diagnosed with multiple myeloma.
Manasanch says research is underway to identify a potential genetic link.
¡°Clinical trials are looking to screen family members of patients with smoldering myeloma to identify early signs of the disease,¡± Manasanch says.
Smoldering myeloma is different from monoclonal gammopathy of undetermined significance (MGUS)
A condition called monoclonal gammopathy of undetermined significance (MGUS) can also lead to multiple myeloma. Patients with MGUS have a low level of abnormal plasma cells and abnormal protein in their blood.
Since patients with smoldering myeloma have even more abnormal plasma cells, they¡¯re more likely to develop multiple myeloma. But MGUS may not ever progress or require treatment.
¡°MGUS is more of a chronic condition that can be monitored over time,¡± Manasanch says.?
Smoldering myeloma treatment depend on your risk of complications
Smoldering myeloma is staged into low-, intermediate- and high-risk disease based on how likely you are to develop health-related complications from your myeloma that require treatment.
These complications can include low bone density, which may lead to fractures and bone pain; they can also include anemia, kidney problems, high calcium in your blood, weight loss and fatigue.
¡°With smoldering myeloma, staging isn¡¯t a gauge of prognosis like staging methods for other types of cancer,¡± Manasanch says. ¡°It¡¯s about your risk of developing complications due to the underlying myeloma.¡±
Patients with low-risk disease have a 20% chance of needing treatment for these complications in the five years after diagnosis. Patients with intermediate-risk disease have a 50% chance of needing treatment, and patients with high-risk disease have a 75% to 80% chance of needing treatment.
¡°Even patients with low-risk smoldering myeloma are at risk of progression,¡± Manasanch says. ¡°So, it¡¯s important to have regular checkups with your care team even when your risk of progression is low.¡±?
Routine bloodwork will help your care team identify any complications and figure out how to approach them effectively. You may experience other effects or complications that are not related to your underlying smoldering myeloma. Those can be managed with other treatments.
Surveillance is an option for smoldering myeloma
Even though patients with smoldering myeloma may experience complications in the future, they may not need cancer treatment if these complications aren¡¯t caused by the myeloma itself, Manasanch says. Patients often enter a period of surveillance, when their care team will ¡°watch and wait¡± to decide when to treat.
If complications are caused by myeloma, you may receive a multiple myeloma diagnosis and undergo treatment. This usually involves a combination of high-dose chemotherapy, called melphalan, with stem cell rescue and modern bio-therapies, such as lenalidomide, bortezomib, carfilzomib, daratumumab or radiation therapy.
Clinical trials are helping to slow the progression from smoldering myeloma to multiple myeloma
Through research and clinical trials, experts are exploring new treatment options for smoldering myeloma to reduce the risk of progression.
¡°For low-risk smoldering myeloma, there are studies investigating treatment with monoclonal antibodies and vaccines,¡± Manasanch says. There are also clinical trials looking into immune-boosting steroids for patients with high-risk disease.
If you¡¯re newly diagnosed with smoldering myeloma, Manasanch encourages you to consider clinical trials.
¡°Clinical trials are changing the way we manage smoldering myeloma,¡± she says. ¡°We¡¯re seeing treatments lead to delayed progression, which is extremely encouraging.¡±
Some of these trials could lead to approval of certain treatment regimens by the Food and Drug Administration (FDA). This could shape treatment options for future patients.
¡°The more patients enroll in clinical trials, the sooner patients can benefit from their findings,¡± Manasanch says.
or by calling 1-877-632-6789.