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Types of treatment for myeloma

The main treatments for myeloma are chemotherapy, steroids and biological therapies. Radiotherapy may also be used for pain control. Bisphosphonates are sometimes used to reduce bone damage. 

If you are fit enough, your specialist may suggest intensive treatment with high dose chemotherapy. The aim of treatment is to try to get the myeloma under control (into remission). Remission means that there is no sign of the myeloma in examinations or tests.

Myeloma without symptoms

If you don't have symptoms, you may not have treatment straight away. Treatment can cause side effects, so if you are feeling well your doctor may keep treatment in reserve.

Myeloma with symptoms

If your myeloma is causing symptoms you are most likely to have chemotherapy treatment. You often have this alongside a steroid and a biological therapy drug. The drugs you have will depend on how the myeloma is affecting you, your general health, and your level of fitness. 

High levels of abnormal protein (immunoglobulin) in your blood can make it too thick. If you have this you may have a treatment called plasmapharesis, which uses a machine to remove the excess protein. 

Treatment of myeloma that has come back

If your myeloma was in remission for longer than 6 months after initial treatment, you may have treatment with the same combination of drugs again. But if it comes back sooner than that, your doctor may suggest a different type of treatment.

Even if it is not possible to get your myeloma into remission, you can have treatment to help control any symptoms it causes.

 

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The main treatments

Chemotherapysteroids and biological therapies are the main treatments for myeloma. Radiotherapy is also used to help control pain. You may also have bisphosphonates to help prevent bone damage and relieve pain. If you are fit enough, your specialist may suggest intensive treatment using high dose chemotherapy with a bone marrow or stem cell transplant.

Your doctor may suggest a treatment called plasmapheresis if the level of abnormal immunoglobulin protein is too high in your blood. Too much protein in the blood can make it too thick and plasmapheresis takes out the excess protein.

The main aim of your treatment is to try to get the myeloma under control. When there is no sign of active myeloma in your body, the myeloma is said to be in remission.

 

Deciding on the right treatment

Which treatments are right for you will depend on

  • How far your myeloma has developed (the stage)
  • Your symptoms
  • The results of your blood and bone marrow tests
  • Your general health and levels of fitness
  • Your personal wishes
 

Treatment for myeloma without symptoms

Doctors also call myeloma without symptoms 'asymptomatic myeloma' or 'smouldering myeloma'. If you have no symptoms, your doctor may suggest keeping a close eye on you, rather than treating you straight away. This is because, over some years, there may be a limit to the amount of treatment that will help and any treatment has some risks and side effects. 

If the myeloma is not causing you problems, your doctor may think it better to keep treatment in reserve. This is a decision that your doctor will discuss with you, bearing in mind your particular circumstances and test results. Your doctor may call this approach to managing your disease 'watch and wait' because they will be keeping a close watch on your health. There is no strong evidence to show that treating asymptomatic myeloma helps people to live longer. But some research has shown that for some people treatment with the biological therapy lenalidomide (Revlimid) and the steroid dexamethasone may lengthen the amount of time it takes for symptoms to show.

Bisphosphonates are drugs that doctors use to help prevent bone damage in myeloma. They also use them to treat high levels of blood calcium. At the moment there is not enough evidence to say if bisphosphonates help people who have myeloma that is not causing symptoms.

 

Treatment for myeloma with symptoms

If you have myeloma that is causing symptoms, you are most likely to have a combination of chemotherapy and steroids. Which drugs you have will depend on how the myeloma is affecting you and on your general health. For example, if you have kidney damage, this will affect the choice of treatment that your doctor can use. Your doctor may also recommend having a biological therapy such as thalidomide,  bortezomib (Velcade) or lenalidomide (Revlimid) alongside the chemotherapy and steroids.

Generally if you are under 70 and are fit enough, your doctor may suggest further intensive treatment with high dose chemotherapy and stem cell transfusion. This is often called a stem cell transplant. Very occasionally bone marrow is used. This is usually your own stem cells or bone marrow, rather than those of another person. 

Once the myeloma is under control (in remission) your doctor may suggest a course of biological therapy to try to keep it under control for longer. This is called maintenance therapy. The drug most commonly used is low dose thalidomide but other biological therapies are being researched in clinical trials.

Older people and those unable to have intensive treatment with a stem cell transplant may have thalidomide with the chemotherapy cyclophosphamide or melphalan, and a steroid. If you are unable to have thalidomide you may have bortezomib (Velcade) in combination with melphalan and prednisolone, or bortezomib (Velcade) and the steroid dexamethasone.

If you have signs of bone damage or have bone pain, you will probably have radiotherapy to that area. If there are areas of damage caused by the myeloma in many places, you may have radiotherapy to a wider area. Your haematologist may refer you to a bone specialist (orthopaedic doctor) if you have areas of bone that are weak and could break easily. You may need to have an operation to try to make the bone stronger.

Bisphosphonates are drugs that can reduce pain and other symptoms when cancer affects the bones. They are particularly good for lowering levels of calcium in your blood. There is now evidence that they may delay the development of bone damage in people with myeloma. So they are sometimes used as active treatment, rather than just to control symptoms. 

A review of all the evidence about bisphosphonates in myeloma, by the Cochrane Collaboration found that bisphosphonates can lower the risk of fractures of the spine and reduce bone pain. Guidelines written by the British Committee for Standards in Haematology (2010) recommend that all myeloma patients who have symptoms should have bisphosphonate treatment.

 

Treatment for myeloma that comes back

Your doctor may call this relapsed myeloma. If your myeloma returns your doctor may suggest treatment with the biological therapy bortezomib (Velcade). If bortezomib is not suitable for you, your doctor may suggest another treatment. This may be a different combination of chemotherapy drugs with or without a biological treatment such as thalidomide or lenalidomide (Revlimid). Some people may have lenalidomide with the steroid drug dexamethasone.

 

Controlling your symptoms

Even if it is not possible to get your myeloma into remission, you can have treatment to help control the symptoms it causes. This may be with chemotherapy. Or you may have radiotherapy to any trouble spots in your bones. Bisphosphonates can also be used to try to prevent and treat bone damage. They can also lower the level of calcium in your blood, if this is too high. You may need blood transfusions to treat the symptoms of anaemia. In this section there is information about controlling myeloma symptoms.

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Updated: 19 December 2013