Treatment
Standard therapy for MGUS and smoldering myeloma is watchful waiting. If the disease progresses to myeloma requiring treatment, standard therapy is based on modern targeted medications and in most cases followed by high-dose chemotherapy and stem cell transplantation. Doctors also commonly prescribe supportive treatments such as bone targeting agents, monoclonal antibodies, IV fluids, anti-viral and blood clot prophylaxis and growth factors to treat symptoms and complications of the disease. Here are some of the treatments used to treat multiple myeloma:
Watchful Waiting/Active Surveillance
To treat early-stage MGUS or smoldering myeloma, the doctor may recommend “watchful waiting” or “active surveillance”. If a patient has no symptoms and low level tumor burden, the side effects of active treatment often outweigh the benefits. These patients are monitored with tests every three to six months to make sure the abnormal plasma cells and the paraprotein have not progressed. If the tests show any cancer progression, active treatment may be started.
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Chemotherapy/Biotherapy
Chemotherapy uses drugs that travel through the bloodstream and attack rapidly dividing cells, such as cancer cells. To treat multiple myeloma, doctors often combine multiple chemotherapy drugs or combine chemotherapy with other treatments. Patients will receive different regimens and combinations depending on their age, health, symptoms, and the stage of the disease. Often times, after initial treatment for multiple myeloma, your doctor will recommend therapy with high dose chemotherapy and infusion of your own stem cells. This type of more aggressive therapy has been shown to increase the time of remission in myeloma patients when used. Biotherapy uses drugs that travel through the bloodstream to specific targets such as the abnormal plasma cells. Nowadays, most myeloma treatments use biologic agents more often than chemotherapy, although chemotherapy is still used. Immunotherapy is also now part of the treatment of multiple myeloma and is used both when patients are newly diagnosed with myeloma or if their myeloma returns after initial therapy. With immunotherapy, the patient's own immune system kills the myeloma with the aid of monoclonal antibodies. A new class of drugs called bispecific T-cell engagers (BITE) are where an antibody simultaneously bind proteins on cancer cells and at the same time engages T-cells to kill myeloma cells. They are also very specific for treating myeloma. The two new FA approved BITES are Teclistimab (targets BCMA) and Talquetemab (targets GPRC5D). Steroids may be included in your treatment plan.
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High-Dose Chemotherapy and Stem Cell Transplantation
This procedure may be recommended for patients that do not respond well to standard-dose chemotherapy or for patients in remission, to prevent a recurrence and extend the remission length. In this procedure, the patient receives extra-high doses of chemotherapy in an effort to eliminate cancer cells. However, since chemotherapy targets all rapidly dividing cells in the body and not just cancer cells, these extra-high doses destroy healthy cells in the blood and bone marrow as well. After chemotherapy, the patient then receives their own blood-forming stem cells to help the body form new, healthy blood cells. This is called ant Autologous Stem Cell Transplant.
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Proteasome Inhibitors
The term targeted therapy means that the treatment affects only cancer cells and has little effect on normal cells. Targeted therapy stops the growth of cancer cells by interfering with signals that cause the cancer to grow or continue to live. The target in many cases is a normal protein present in both cancer and normal cells, but concentrations of the protein can be higher in cancer cells. Therefore, when the target is blocked, the cancer cell is affected more than is the normal cell. One form of targeted therapy, proteasome inhibitors, including bortezomib, ixazomib and carfilzomib, block abnormal cell function and growth. Steroids may be taken with the drug regime your physician advises. Research in this field is very active and new drugs with little toxicity may soon be available to treat myeloma in this way.
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Monoclonal Antibodies
Another type of therapy for multiple myeloma is through the use of monoclonal antibodies. Monoclonal antibodies are proteins produced by the same cluster of cells ad consist of identical antibody molecules. Monoclonal antibodies that target specific markers on the myeloma cells are now used routinely in the treatment of multiple myeloma. Most side effects to monoclonal antibodies are related to mild allergic reactions at the time of receiving the antibody.
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Immunomodulators
This is another form of therapy found to be important in the management of myeloma. This class of drugs, which includes thalidomide and lenalidomide, act through multiple ways to stimulate the death of cancer cells. These drugs can reduce the number of new blood vessels required for growth of new tumor cells and stimulate the activity of normal cells which are known to kill cancer cells. Intense research is also being conducted in the development of effective use of this type of therapy in myeloma.
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Radiation Therapy
Radiation therapy uses high energy, radioactive waves to target and kill cancer cells. These waves damage the cancer cells’ DNA and cause them to die. Radiation therapy is not usually a primary treatment for multiple myeloma, in which the myeloma cells have spread throughout the bones in the body. However, radiation therapy may be used to treat solitary plasmacytomas, or a single lump of malignant plasma cells in one location in the body. Radiation therapy may also be given as a palliative therapy, to treat areas of weakened bone or to shrink tumors that are causing problems. This may help relieve pain and other symptoms of the disease.
Clinical Trials
Clinical trials are studies of new treatments that show promise in treating a disease. Clinical trials allow patients to test out new treatments before they are available to the public. Clinical trials may test a new drug that has never been used before, or they may test a drug or drug combination that has not been used for a specific type of cancer. A clinical trial may be a groundbreaking treatment or it may have no effect. Talk to your doctor about the pros and cons of participating in a clinical trial.
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Palliative/Supportive Care
Palliative care is any form of treatment given to cancer patients to relieve symptoms and side effects of the disease and improve quality of life. The goal of palliative care is not to cure the disease, but to make the patient as comfortable as possible. The doctor may give bisphosphonates to treat bone damage caused by multiple myeloma, IV fluids to treat hypercalcemia, and plasmapheresis to remove M-proteins from the blood.
