When Multiple Myeloma Relapses Quickly–Judgment Calls

When your multiple myeloma comes back within about a year, your disease is generally classified as ‘high risk.’ We acknowledge that this sort of language can actually be even more frightening for some people, but it’s important to understand at this point doctors will often talk to you about a more aggressive treatment regimen in the management of the relapse.

The quicker you contain the myeloma, the better the patient does, says Dr. Vincent Rajkumar who treats patients at The Mayo Clinic.

Younger and more fit patients with relapse may consider getting a stem cell transplant from a donor, according to Dr. Rajkumar. They call this an “allogenic transplant” which is different from the “autologous transplant” that is more commonly done as a second step in treatment using a myeloma patient’s own cells. Allogenic transplants can be given from a close relative or a donor with the right matching characteristics. These transplant procedures are very challenging for the body, as they are in essence a way to deliver extremely high doses of chemotherapy in the hope of rebuilding the body’s blood and immune system.

Dr. Rajkumar also says that a combination of four drugs may also be considered so the myeloma can be controlled more quickly.

A lot of treatment at this stage of myeloma involves a judgement call. One of the key drivers for decision making around aggressive myeloma relapse is how you as the patient react to lenalidomide (brand name Revlimid) as a therapy.

With this factor in mind, there are eight to ten different four-drug combinations which can be tried in the management of aggressive myeloma which may include the following drugs:

• Velcade (bortezomib), Kyprolis (carfilzomib), and Ninlaro (ixazomib): These are proteasome inhibitors. In other words, they disrupt the mechanism by which cancer cells break down proteins. This build-up of protein within the cell eventually causes the cells to die.
• Revlimid (lenalidomide) and Pomalyst (Pomalidomide): These are known as immunomodulatory drugs. In other words, they activate your immune system to target cancer cells and kill them like they would any other infection.
• Dexamethasone: This is a steroid drug that prevents inflammation and associated pain from myeloma, and it can even help kill myeloma cells at high doses.
• Dara (Daratumumab): This is known as an immunotherapy. More specifically, it is a monoclonal antibody that ‘tags’ cancer cells for recognition by the immune system.

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