First treatment for myeloma

Your first treatment is also called first line treatment. Your team plans your treatment depending on your:

• symptoms
• results of blood tests, bone marrow tests and scans
• general health and levels of fitness 
• personal wishes

What is the aim of treatment?

The main aim of your treatment is to try to get the myeloma under control. Myeloma is not usually curable but treatment can control it.

When there's no sign of active myeloma in your body, the myeloma is said to be in remission. Or your doctor might say you have a partial remission, or a plateau. This means there might still be signs of myeloma, but it is under control and at a steady level.

Phases of treatment

There are phases to your first line treatment:

• The first phase is to get rid of as much myeloma as possible and get you into remission. You usually have a combination of targeted drugs, chemotherapy and steroids. Doctors call this induction treatment .
• The second phase of treatment is a stem cell transplant if you are well enough. Doctors call this consolidation treatment . Or you continue with drug treatment if you aren't well enough for a transplant. 
• The third phase aims to keep you in remission for even longer. Doctors call this maintenance treatment . After a stem cell transplant, you might take a drug called lenalidomide as maintenance treatment.

How treatment works

Targeted drugs for myeloma

Cancer cells have changes in their genes (DNA) that make them different from normal cells. These changes mean that they behave differently. Cancer cells can grow faster than normal cells and sometimes spread. Targeted cancer drugs work by ‘targeting’ those differences that a cancer cell has.

There are many types of targeted drugs which work in different ways. For first line myeloma treatment, the most common drugs you might have are:

• bortezomib – this is a type of targeted drug called a proteasome inhibitor
• daratumumab - this is a type of targeted cancer drug called a monoclonal antibody (MAB)
• thalidomide or lenalidomide – these are types of targeted cancer drugs

Chemotherapy for myeloma

Chemotherapy uses anti cancer (cytotoxic) drugs to destroy myeloma cells. The drugs circulate around the body in the bloodstream.

The most common types of chemotherapy drugs you might have for myeloma include:

• cyclophosphamide
• melphalan

Steroids

Steroids are naturally made by our bodies in small amounts. They help to control many functions including the immune system, reducing inflammation and blood pressure. Dexamethasone is a type of steroid.

Stem cell transplant

You have a stem cell transplant after very high doses of chemotherapy. The chemotherapy kills the myeloma cells and also the stem cells in your bone marrow. 

After the chemotherapy you have the new stem cells into your bloodstream through a drip. You usually have a stem cell transplant using your own stem cells. 

What treatment will I have?

Your first treatment is likely to be a combination of different types of drugs. This drug combination depends on whether you are able to have high a stem cell transplant. Your doctors will decide this. They consider your general health and level of fitness, as well as your age.

When you are first diagnosed you may also need treatment for any symptoms that you have. These symptoms might include bone pain, tiredness and infections.

If you are able to have a transplant

Your first treatment might be one of the following:

• bortezomib, cyclophosphamide and dexamethasone  (VCD)
• daratumumab with bortezomib, thalidomide and dexamethasone (DVTD)

You usually have treatment for four to six months. Then if you are fit enough, your specialist might suggest intensive treatment. This uses high dose chemotherapy with a stem cell transplant.

After the transplant, your doctor might suggest you take lenalidomide. This is called maintenance treatment. It aims to keep you in remission for as long as possible. You usually carry on taking lenalidomide until your myeloma comes back. And so long as your side effects are not too severe.

If you can’t have a transplant

You might have one of these treatment combinations:

• lenalidomide and dexamethasone
• daratumumab, lenalidomide and dexamethasone

Or your doctor might ask you if you would take part in a clinical trial with a new combination of drugs.

You might continue until the treatment is not controlling your myeloma.

How you have treatment

You have treatment in cycles or blocks. Each cycle usually lasts for between 21 and 35 days. You have some drugs every day and others weekly. After each cycle of treatment, your team will check your side effects. They will also check how well treatment is working.

Most people have between 4 and 6 cycles of treatment. If you're having lenalidomide, you might carry on with this until it stops working.

Treatment can be:

• tablets alone
• tablets together with an injection under the skin
• an injection into the vein as a drip (intravenously)

You usually have treatment as an outpatient unless there is another reason to be in hospital. Most treatments mean that you go to the hospital once a week. You are usually at the hospital for about an hour if you're having just an injection under the skin.

Other treatments to prevent problems

You might have other treatments to treat symptoms of myeloma. Or to prevent problems caused by the myeloma.

Other treatments you might have for myeloma include:

• bisphosphonates
• radiotherapy
• supportive treatments such as antibiotics or blood products

Bisphosphonates

Myeloma can damage your bones which can cause pain and fractures. To try to prevent this your doctor will offer you a medicine called a bisphosphonate. Bisphosphonates are drugs that help to treat some types of cancer that cause bone damage.

The most common bisphosphonates are pamidronate and zoledronic acid (Zometa). You have them into the vein as a drip (intravenously) every 4 weeks.

Radiotherapy

Radiotherapy uses high energy waves similar to x-rays to kill cancer cells.

Radiotherapy aims to kill cancer cells in the bone. This can help to reduce pain and slow down the bone damage. This includes the bones of the spine. These bones protect the spine. Damage to the spinal bones can press on your spinal cord and cause pain and other changes.

Treatment to prevent or control problems

Myeloma and its treatment can cause problems. Supportive treatments can help to either prevent or control these problems. Supportive treatments include:

• preventing and treating infections
• preventing blood clots
• blood products
• pain management
• plasmapheresis to remove excess protein from the blood

Follow up and monitoring

You will have regular tests during and after treatment.

You will usually have blood and urine tests at each visit. This is to check whether the myeloma is active again and whether you need more treatment. 

Your team will ask about how you are feeling, whether you had symptoms or side effects, and if you are worried about anything. You might need x-rays or scans (such as CT, PET or MRI) if you have new bone pain. 

Let your team know if you are worried or notice any new symptoms between appointments.

Coping with myeloma

Coping with a diagnosis of myeloma can be difficult. There is lots of support available inlcuding specialist nurses. It is important to get the support you need.