Relapsed Multiple Myeloma Treatment Choices
- Your age, health, and the genetic make-up of your cancer cells all factor into the decision of which treatment to choose for a relapse.
- Doctors treat multiple myeloma with a cocktail of different drugs.
- It’s not clear which treatment combination is best, and you may try more than one.
- New medications such as Sarclisa and Xpovio treat multiple myeloma in a different way than older drugs.
To narrow down the choices, your doctor will look at factors like:
- Your age
- The aggressiveness of your relapse
- Whether you have a high- or low-risk cancer
No one multiple myeloma treatment is right for everyone. Doctors choose from a few "cocktails" combinations of drugs. A typical cocktail might include two of these drug types, plus a steroid:
- A proteasome inhibitor such as bortezomib (Velcade) or carfilzomib (Kyprolis)
- An immunomodulatory drug such as lenalidomide (Revlimid) or thalidomide (Thalomid)
- A monoclonal antibody such as daratumumab (Darzalex) or elotuzumab (Empliciti)
Often people get a combination of Darzalex, Revlimid, and the steroid dexamethasone. Another common combination includes Revlimid, Velcade, and dexamethasone. Doctors call this "RVD lite."
"We don’t know which one is going to be better, to be honest," Dr. Gowin says. She adds that you're likely to go on both treatments at different points in your journey.
New Ways to Treat Multiple Myeloma
A couple of recently approved medications have given oncologists even more options. One is the monoclonal antibody isatuximab (Sarclisa). It binds to a protein called CD38 on the surface of multiple myeloma cells and targets them for destruction. Dr. Gowin says she sometimes prescribes Sarclisa for people who haven't improved enough on Darzalex.
In December 2020, the FDA approved the drug Selinexor (Xpovio) for relapsed multiple myeloma. Xpovio is a nuclear transport inhibitor. It blocks a protein called XPO1, which helps multiple myeloma cells multiply. Doctors usually give Xpovio together with Velcade and dexamethasone.
Doctors were reluctant to prescribe Xpovio at first because it has so many side effects, including nausea, vomiting, and diarrhea. But over time, they learned how to manage these side effects. "As a whole, that class of medication has become more tolerable because we have more experience with it now," Dr. Gowin says.
Immunoconjugates are another new treatment. They're made up of two parts: a monoclonal antibody to lock onto the cancer cells and a drug to destroy these cells.
Because these treatments are so new, it's not clear how they should fit together. "We’re still trying to find our sequence," Dr. Gowin says.
Exciting Therapies on the Way
Even more new therapies are coming down the research pipeline, Dr. Gowin says. One is bispecific T-cell therapy, nicknamed BiTE. One “arm” of this treatment hooks onto myeloma cells while the other hooks onto the immune system. BiTE brings the cancer close to the immune cells, which then destroy them.
One way to try a treatment that hasn’t been approved is by joining a clinical trial. Ask your oncologist if any studies that are currently enrolling could be a good match for you.