Treating Otherwise Healthy High-Risk Multiple Myeloma Patients
- Standard multiple myeloma treatment generally consists of three phases: induction therapy, consolidation therapy and maintenance therapy.
- Induction therapy involves using a combination of chemotherapy drugs to induce remission, consolidation therapy includes an autologous stem cell transplant to improve the chance of long-term remission and maintenance therapy aims at keeping your multiple myeloma in remission for as long as possible.
- High-risk multiple myeloma is a serious diagnosis, but it is treatable. With the help of a skilled oncologist, you can enter remission and live a long and fulfilling life.
- Induction therapy: A combination of chemotherapy drugs are used to induce remission
- Consolidation therapy: Includes autologous stem cell transplant to improve the chance of long-term remission
- Maintenance therapy: Aims at keeping your multiple myeloma in remission for as long as possible
Phase 1: Induction Therapy
The induction therapy phase combines multiple categories of drugs to attack myeloma cells. Common drug categories include:- Immunomodulators: Lenalidomide
- Proteasome inhibitors: Bortezomib and Carfilzomib
- Steroids: Dexamethasone
- Monoclonal antibodies: Daratumumab
Your regimen is customized based on many factors, such as overall health, age, and the stage of multiple myeloma. Treatment varies but is usually a three-part or four-part cycle.
Phase 2: Consolidation Therapy
The second phase of treatment focuses on keeping the cancer at bay for as long as possible. For most, this requires an autologous stem cell transplant.
During stem cell transplant, your own healthy stem cells are removed, frozen, and then later given back after high-dose chemotherapy. This step is important for those with high-risk multiple myeloma, as it can improve the chance of long-term remission.
Transplantation can be done in an inpatient or outpatient environment, depending on your cancer facility. Some may give you the option to decide whether you prefer to be admitted during this time, or if you’d like to receive therapy as an outpatient.
Regardless of your decision, a transplant requires specialized care and close monitoring. “Outpatient transplant involves daily checkups, daily labs, and at least half the patients have to get admitted for fever, dehydration, or other problems,” explains Dr. Hoffman.
“On the other hand, a lot of our patients see the benefits of being inpatient,” adds Dr. Hoffman. Inpatient transplant allows you to be closely monitored and have any potential problems addressed immediately.
On average, a stem cell transplant requires between two and three weeks of hospitalization. The transplant itself is an intense treatment. High-dose chemotherapy, along with the associated side effects, can lead to a multitude of problems. You may experience nausea, vomiting, diarrhea, and hair loss.
Transplant patients may also experience a low white blood cell count (neutropenia), which can lead to an increased risk of infection. After the transplant, you’ll remain in remission until there is a recurrence of multiple myeloma.
Phase 3: Maintenance Therapy
For those who have completed induction therapy and autologous stem cell transplant, the goal of maintenance therapy is to prolong remission for as long as possible. This is accomplished by giving one or more drugs with targeted activity against myeloma cells.
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Maintenance drugs are taken continuously for as long as remission is maintained. Revlimid (lenalidomide), an immune-modulating therapy, is the standard drug used for this purpose. However, it’s important to note that many patients can eventually develop resistance to these drugs.
Sometimes, especially for high-risk patients, a two-drug maintenance regimen is used. For this, an oral medication is typically combined with a maintenance injection.
Two common maintenance injections include:
- Daratumumab: A monoclonal antibody that targets CD38, a protein found on the surface of myeloma cells
- Velcade (bortezomib): A multiple myeloma drug that inhibits the breakdown of proteins in cells
Throughout this phase, doctors will monitor you with lab work and imaging tests to ensure your body’s tolerating the therapy and that the myeloma cells have not returned. If therapy becomes toxic or is no longer effective, your doctor may adjust your dose, prescribe a different drug, or take a break from therapy for a period of time.
“It seems that the maintenance drugs in an indefinite fashion are ideal, but the primary benefit is maintenance for the first year or two after the conclusion of induction or stem cell transplant,” adds Dr. Hoffman. “So as long as we can get patients through that first year or two, we can pull back on maintenance if they’re not tolerating it well.”
Although high-risk multiple myeloma is a serious diagnosis, it is treatable. With the help of a skilled oncologist, you can enter remission and live a long and fulfilling life.
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