Current Approach to Treatment for Multiple Myeloma

Patients Hope for New Agents and Longer Survival

A stethoscope on a laboratory bench. Clinical trial of venetoclax yields positive results.

Multiple myeloma (MM) accounts for nearly 10 percent of all blood cancers in the United States, yet the public does not generally know much about this malignancy, or its treatment. It’s a cancer of the antibody-producing line of cells, the plasma cells, and it’s more common in older persons, and in those with African ancestry. New treatments continue to emerge, and there is hope that outcomes will continue to improve.

Chemotherapy, biological agents, targeted therapy, corticosteroids, radiation therapy, auto- and allogeneic transplant are the methods of treatment.

Risk Groups

Patients diagnosed with MM are evaluated and classified into risk groups, which helps not only in developing a prognosis but also in deciding how to begin treatment.

Risk is determined based on genetic profiles using fluorescence in situ hybridization (FISH) studies on the bone marrow, and also by other indicators and features of the myeloma. This results in 3 separate risk groups: high-, intermediate-, and standard risk.

Standard or Intermediate Risk

Chemotherapy, biological agents, targeted therapy, corticosteroids, radiation therapy, and bone marrow transplants are the methods of treatment. High-dose chemotherapy with autologous hematopoietic cell transplantation (HCT) is the preferred approach for patients with standard or intermediate risk myeloma, but not all patients with MM are eligible for a transplant or wish to have HCT.

And even within the same risk category, treatment is not a one-size-fits-all proposition. New trials continue to inform the approach to care for individual patients.

Aspects of treatment depend not only on the risk category, but also on a variety of factors including patient wishes, the presence of other chronic illnesses, and whether HCT is planned.

Lenalidomide plus low-dose dexamethasone is an oral regimen that has been used initially in standard-risk myeloma. The protease inhibitor bortezomib has been used alone and in combination with other agents for many patients with MM.

High Risk

Patients with high-risk MM are usually encouraged to enroll in a clinical trial with a new therapeutic strategy since high-risk disease responds poorly to conventional treatment. Clinical trial participation can mean a chance to receive potentially life-extending treatment. According to the Multiple Myeloma Research Foundation, there are over 400 myeloma trials currently on the books.

Many new drugs have been approved in recent years, and several more are expected within the next year or so. For patients whose response to therapy does not last, retreatment with the same agent is sometimes an option, but this depends on a number of factors, including how the patient responded prior to relapse, how well the patient tolerated the prior therapy, and how long the response to the prior treatment lasted.

Kidney Injury in Multiple Myeloma

For a variety of reasons, patients with multiple myeloma commonly also have kidney injury. About 20 percent of patients with MM have impaired kidney function when they come to medical attention. Some kinds of myeloma produce proteins that can lead to kidney injury, and severe kidney failure is an important complication of myeloma. For patients whose kidney function may be compromised, treatment can be planned with the remaining kidney function in mind. In some cases, plasmapheresis is used to remove harmful proteins from the circulation.

Overview of Current Treatments

The need for newer and better therapies for MM is widely recognized--by patients, advocates, and the scientific community, including researchers and clinicians specializing in Hematology-Oncology.

Current therapy has improved survival over the past 30 years--it's practically doubled. This means that people with MM may go through many rounds of treatment during the course of their illness, which may prolong their life but it will not offer them a cure. Stem cell transplantation may be part of the treatment plan for some, but this is not offered as an option to all patients. In older patients, continuous therapy may be an option with a survival benefit, and therapies need to be relatively well-tolerated in order to do so.

Dr. Hani Houssoun, a Hematologist/Oncologist interviewed by MedPage Today, notes, “All the drugs are not equivalent in terms of risk-benefit ratio,” specifically observing that newer drugs like bortezomib are more favored lately, but that is "not to say that the anthracycline or alkylating agents are out"; rather, they may not be considered first. There is also a lot of work being done and scientific debate about the number of agents that should be combined in aggressively treating MM.

Updated February 2016, TI.

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Siegel R, Ma J, Zou Z, Jemal A. Cancer statistics, 2014. CA Cancer J Clin. 2014;64(1):9-29.

Multiple Myeloma Research Foundation. Search for Multiple Myeloma Clinical Trials. https://myeloma.trialx.com/ask/ Accessed November 2014.

Waxman AJ, Mink PJ, Devesa SS, et al. Racial disparities in incidence and outcome in multiple myeloma: a population-based study. Blood. 2010;116(25):5501-5506.

Rajkumar SV. Multiple myeloma: 2012 update on diagnosis, risk-stratification, and management. Am J Hematol 2012; 87:78.

Blade J, Fernandez-Llama P, Bosch F, et al. Renal failure in multiple myeloma: presenting features and predictors of outcome in 94 patients from a single institution. Arch of Intern Med. 1998;158(17):1889-1893.

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