Biological therapy for myeloma

Biological therapies are treatments that use natural substances from the body, or that change the way that cells signal to each other. They  stimulate the body to attack cancer cells or control their growth. Biological therapies used in myeloma treatment include thalidomide, bortezomib (Velcade) and lenalidomide (Revlimid).

Thalidomide is a drug that affects how cells signal to each other. It can affect all sorts of cell processes, including the division and growth of cancer cells. Thalidomide is also known as an anti angiogenic drug. Angiogenesis means growth of new blood vessels. Cancers need to grow their own blood vessels as they get bigger. Without its own blood supply, a cancer cannot continue to grow. So anti angiogenic drugs block the growth of new blood vessels.

We don't fully know how thalidomide works in myeloma. There are probably quite a few different ways. We know it can slow the growth of myeloma cells. It may work directly on the myeloma cells, or it may encourage the immune system to attack them. 

Thalidomide is used to treat newly diagnosed myeloma in people who can't have high dose chemotherapy with a stem cell transplant. It is given with the chemotherapy drug melphalan, and the steroid prednisone. Some people have thalidomide with cyclophosphamide chemotherapy and the steroid dexamethasone.

Thalidomide may also be used for myeloma that has

• Come back after responding to treatment (relapsed disease)
• Stopped responding to other treatments (resistant or refractory disease)

Or it may be used as a maintenance therapy, to help keep myeloma in remission after successful chemotherapy treatment.

We know quite a lot about thalidomide for relapsed or resistant disease. Thalidomide doesn't help everyone with myeloma, but it has been shown to work in about 3 to 6 out of 10 people with relapsed or resistant disease (30 to 60%). You might have it on its own, with steroids, or with steroids and chemotherapy. Research into thalidomide continues in order to find out the best time to use it and which dose to use.

As a maintenance therapy, studies have been done, and continue to be done. But we'll need to follow patients' progress for a long time before we really find out how well it works. There is information about thalidomide research on our myeloma research page.

You take thalidomide as a tablet every day. It causes sleepiness so doctors recommend that you take it at night. Some people are very worried about taking thalidomide because of its reputation for causing birth defects. It is very dangerous in pregnancy. If you are a woman of child bearing age you must use contraception from 4 weeks before starting thalidomide until 4 weeks after treatment has finished. You will also need to have a pregnancy test at the start of every treatment cycle. If you are a man and have a partner of child bearing age it is also important to use contraception whilst taking thalidomide and for one week after treatment ends. 

The side effects include sleepiness, dizziness, constipation, pins and needles or numbness in fingers and toes, skin rashes and low blood cell levels. It can also increase the risk of blood clots. Blood clots have been shown to affect up to 25 out of 100 people (25%) having this treatment. Doctors may try to prevent this happening by giving drugs that thin the blood to people thought to be at higher risk of clots. So you may need treatment with medicines to reduce the risk of clots.

Bortezomib (Velcade) interferes with the signals that cells use to control their growth. It is a type of drug called a proteasome inhibitor. That means that it stops the breakdown of proteins within cells. This leads to a build up of protein, which makes the cell die. For reasons we don't fully understand, cancer cells seem to be more easily damaged by bortezomib than healthy cells.

Bortezomib is used for 

• People who can't have thalidomide treatment or high dose chemotherapy with a stem cell transplant 
• People whose myeloma has come back after previous chemotherapy, and who are unable to have, or have had, a stem cell transplant

You usually have bortezomib with chemotherapy and a steroid.

You can have bortezomib as an injection into a vein or as an injection just under the skin (subcutaneously). You have it in cycles of treatment, with breaks in between. You usually have treatment twice a week for 2 weeks and then have a one week break. 

There are some side effects, but they are often quite mild. Bortezomib can cause tiredness, sickness, diarrhoea or constipation, loss of appetite, pins and needles or numbness in fingers and toes, and an increased risk of bruising or bleeding. You may also have an increased risk of getting shingles.

Lenalidomide (Revlimid) works in a similar way to thalidomide. It blocks cancer cells from developing new blood vessels. Lenalidomide is used to treat people with myeloma who have had previous treatment. In combination with the steroid dexamethasone it can slow the growth of myeloma.

Lenalidomide comes as capsules that you swallow. You usually take the capsules daily for 3 weeks and then have a week with no treatment. This cycle is repeated for as long as the treatment controls the myeloma or until side effects become too great. You should take the capsules at the same time each day. You also take dexamethasone with this treatment.

Because it is similar to thalidomide, lenalidomide may cause birth defects if it is taken during pregnancy. But its side effects are different from thalidomide. They include lowered production of blood cells by the bone marrow, tiredness and weakness, constipation or diarrhoea, nausea, blood clots, skin rashes and muscle cramps.

There is detailed information about biological therapies in the cancer treatment section. There is information about research into biological therapies for myeloma on the myeloma research page.