The multiple myeloma treatment depends on many factors including but not limited to the type of plasma cell dyscrasia, the overall stage of the disease, performance status of the patient, patient’s preference, along with other factors. Following are the preferred treatment approaches for different plasma cell disorders, but the final decision is taken after clinical assessment of the patient by an oncologist.
|Multiple myeloma Category||Preferred Treatment|
|Solitary Plasmacytoma||Radiation therapy is the preferred treatment for solitary plasmacytoma. In case of extramedullary plasmacytoma, surgical resection of the affected soft tissue followed by radiation therapy may be employed.|
|MGUS||Patients with MGUS are recommended to be followed-up closely without treatment. Only about 1% of patients with MGUS face progression to multiple myeloma per year.|
|Smoldering multiple myeloma||Patients with smoldering multiple myeloma are also recommended to be followed-up closely without treatment. In case of any sign of disease progression, chemotherapy can be employed as the first line of treatment.|
|Patients with the symptomatic disease are recommended to be treated with induction therapy constituting multiagent regimen (mostly a combination of corticosteroid, immunomodulatory drug, and proteasome inhibitor).
After completion of the induction therapy, patients who are the good candidate for stem cell transplant may undergo the procedure if there is an indication.
Maintenance treatment is continued after induction in most patients.
Following is the brief description of various treatment types employed for multiple myeloma:
1.Chemotherapy: Chemotherapy means treatment with anti-cancer drugs that kill or decrease the growth of rapidly-growing cancer cells. Chemotherapy is employed in combination with other therapeutic agents for the management of multiple myeloma. Depending on the physician’s preference and patient’s condition, it may also be combined with immunomodulatory drugs and corticosteroids to accelerate the benefit achievement. Many pharmaceutical companies are conducting a number of clinical trials to find out new drugs and drug-combinations with increased efficacy and specificity to target multiple myeloma cells. Chemotherapy is generally associated with several side effects due to its effect on normal body cells apart from cancerous cells.
2.Corticosteroids: These are a category of drugs which are structurally similar to cortisone, a hormone produced by the adrenal cortex. Examples of corticosteroids include dexamethasone, prednisone, etc. that are generally employed in the treatment regimen for multiple myeloma. These drugs may have side effects like hyperglycemia, weight gain, mood changes, weakness in bones etc.
3.Immunomodulating agents (IMiDs): These are a category of drugs that alter the immune system to produce their effects. Drugs such as thalidomide, lenalidomide, and pomalidomide are used for the treatment of multiple myeloma in combination with other therapeutic agents.
4.Proteasome inhibitors (PIs): These are a category of drugs that inhibit the proteasome, an enzyme complex in cells that degrade many cell division controlling proteins. These drugs mainly affect cancer cells and bring about apoptosis (programmed cell death) in these cells by inhibiting degradation of pro-apoptotic proteins. These drugs are used for the treatment of multiple myeloma in combination with other therapeutic agents or alone when other therapeutic agents fail. Examples of PIs include Bortezomib, Carfilzomib, and Ixazomib.
5.Targeted Therapy: Targeted drugs are designed to target a specific gene or protein characteristic of the myeloma cells. Examples of targeted drugs for multiple myeloma include Daratumumab that targets CD38 protein on the surface of myeloma cells and Elotuzumab that targets SLAMF7 protein in the myeloma cells.
6.Histone deacetylase (HDAC) inhibitors: HDAC is an enzyme that brings about deacetylation of histones, a group of basic proteins that help in coiling of DNA to form chromatin. The HDAC inhibitors, for example, panobinostat can arrest the growth and differentiation of myeloma and turn on apoptosis in malignant cells. These agents can be used in combination with other therapeutic drugs or alone in the treatment of multiple myeloma resistant to other treatments.
7.Bisphosphonates: Bisphosphonates (e.g. Zoledronic acid and Pamidronate) are a class of drugs which helps in maintaining bone density and reduce the occurrence of skeletal-related events. Normally, bones are constantly remodeled by two types of bone cells: osteoblasts (they increase bone density) and osteoclasts (they decrease bone density). Bisphosphonates decrease the activity of osteoclasts by inducing apoptosis (natural cell death) in them, and thus, help in maintaining bone density and to relieve symptoms of bone metastasis.
8.Radiation Therapy: Radiation therapy (or radiotherapy) uses high-energy x-rays or other high-energy radiations which are directed to the affected area to kill cancerous cells. For multiple myeloma treatment, an external radiation source (external beam radiation therapy) is generally employed, whenever indicated. Radiotherapy is mostly used to treat solitary plasmacytoma or used for palliation of symptoms of the advanced-stage disease such as pain, swelling, or spinal cord compression.
9.Surgery: Surgery is rarely employed for the treatment of multiple myeloma but it may be employed for treating solitary plasmacytoma especially that affecting soft tissue, for example, the tissue lining the sinuses.
10.Stem Cell Transplant (SCT): The SCT is generally employed for the treatment of multiple myeloma in patients who are the good candidate for SCT (younger patients in good health) and in whom there is an indication to do the same.
Following are major types of stem cell transplant techniques:
- Autologous SCT: In this technique, patients own stem cells are first collected from the healthy bone marrow tissue or peripheral blood (free from disease). Then, the patient receives high-dose chemotherapy to kill all cancerous cells. The collected stem cells are re-administered to the patient which slowly replenish the blood cells in the patient body. Sometimes, a second autologous SCT is employed 6 to 12 months after the first SCT. This is known as Tandem SCT. Various research studies have revealed that Tandem SCT can be more beneficial than single SCT in some selected patients
- Allogeneic SCT: In this technique, healthy stem cells to be administered to the patient after high dose chemotherapy are obtained from another person known as the donor. It is very important that donor is a close blood relative (preferably a sibling) so that donor cells closely match with the patient’s cell types. There is risk of graft-versus-host disease in which the new immune cells originated from donor’s cells attack the host cells.
It is very important to assess the benefits of each treatment option versus the possible risks and side effects before making a treatment decision. Sometimes, patient’s choice and health condition are also important to make a treatment choice. Following are ultimate goals of treating multiple myeloma cancer:
- Prolongation of life.
- Reduction of symptoms.
- Improvement of overall quality of life.
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