By Dr Ananya Mandal, MD
The majority of multiple myeloma cases cannot be cured and treatment is aimed at bringing the cancer under control and treating symptoms such as bone pain and anemia.
The choice of treatment depends mainly on how advanced a patient’s disease symptoms are. Asymptomatic multiple myeloma, also called smouldering myeloma, is often not treated immediately and the patient’s health is closely monitored instead, an approach called watchful waiting. In this case, treatment is only initiated when there are signs of cancer growth and symptom onset.
When a person does start treatment, it may be non-intensive in the case of older, less fit patients or intensive if a patient is younger and healthier. Intensive therapy is thought to be too toxic for older or less fit patients. Although there is no particular age cut-off age for determining which type of therapy a patient has, generally those under 65 years are more likely to be candidates for intensive therapy while those age over 70 years are more likely to be given non-intensive therapy.
Either way, patients usually start a combination of three anti-myeloma medicines. In those who undergo intensive therapy, this is usually referred to as induction therapy, as it is followed up later by additional approaches such as high-dose therapy or stem cell transplantation. In older or less fit patients, this medication is referred to as frontline treatment, although it may be given in modified doses.
The treatment usually includes a combination of a chemotherapy medication such as cyclophosphamide, a steroid such as prednisolone and either a thalidomide or a velcade.
This is an agent that belongs to a new class of anti-cancer drug called the proteasome inhibitors and is particularly effective against myeloma cells. All cells have a protein inside them called the proteasome which helps the cell to recycle the substances that stimulate their growth as well as eliminate substances detrimental to their survival. Bortezomib blocks the function of this proteasome in myeloma cells, which causes them to die.
Radiation therapy may be used to relieve bone pain by directing high-energy beams of radiation at weak and damaged bones. This therapy reduces the amount of cancer cells inside the bone, allowing a window of time for the bone to repair. Usually, one or two sessions are required for the pain to start reducing.
These drugs can be used to reduce bone damage and blood calcium levels. Myeloma cells disrupt the process bone goes through to replace old cells with new ones, leading to weakened bones. Bisphosphonates help to prevent the disruption of this process, therefore reducing the risk for fracture and bone pain.
Other general treatments that may be used include blood transfusion to increase the red blood cell count in cases of anemia and surgery to repair or reinforce damaged bones.
Reviewed by Sally Robertson, BSc