This summer I am sharing guest blogs from a variety of experts. This week’s blog is the fourth in a multi-part series about multiple myeloma from my colleague Dr. Margaret Henderson who has a Doctor of Pharmacy degree from the University of Colorado.
–Dr. Stephen Vogt
Welcome to the fourth installment in a 5-part patient education series on multiple myeloma. Multiple myeloma, a form of cancer affecting the bone marrow, is diagnosed in approximately 30,000 Americans each year. In this disease, malignant plasma cells (which are a type of white blood cell) start growing out of control and can create multiple tumors in the bones. The cancerous plasma cells can also crowd out other cells in the bone marrow, leading to lower blood counts and anemia.
TREATMENT OF MULTIPLE MYELOMA
Multiple myeloma treatments have improved over the years, leading to better and more innovative treatments which has translated to prolonged survival rates. There are four main treatment options, which can be used as monotherapy or in combination with other treatment modalities to improve outcomes and survival.
Non-Chemotherapy Agents: These include immunomodulatory agents, proteasome inhibitors and monoclonal antibodies.
- Immunomodulatory Agents – These agents use the body’s own immune system to fight myeloma cells.
- Revlimid (lenalidomide)
- Pomalyst (pomalidomide)
- Thalomid (thalidomide)
- Proteasome Inhibitors – These agents block the breakdown of proteins in cells, so that the proteins build up and the cell dies. This is especially effective in multiple myeloma patients because of the excessive amount of proteins being made by the myeloma cells.
- Velcade (bortezomib)
- Kyprolis (carfilzomib)
- Ninlaro (ixazomib)
- Monoclonal Antibodies – These agents attack antigens on the surface of the cancer cells, which the cancer cells use to evade the body’s immune system from detecting and attacking it as a foreign entity. Also called immune therapy, this has become an exciting and explosive discovery in the field of cancer research. There are several medications on the market today, which rev up the body’s own immune system to fight different types of cancers.
- Darzalex (daratumumab)
- Empliciti (elotuzumab)
Chemotherapy: Defined as the treatment of disease by the use of chemical substances, especially for the treatment of cancer by cytotoxic and other drugs. The goal of chemotherapy is to stop or slow the growth of cancer cells and although they are effective at attacking cancer cells, they can also affect healthy, non-cancerous cells.
- Alkeran (melphalan)
- Cytoxan (cyclophosphamide)
- Adriamycin (doxorubicin)
- Doxil (liposomal doxorubicin)
- Farydak (panobinostat)
Stem Cell Transplant: This is a procedure that involves harvesting healthy stem cells from the patient or a matched donor. In multiple myeloma patients, this is accomplished by removing a bone marrow sample (approximately one liter) from the hip bone using a needle and syringe. Once the stem cells have been harvested, the patient undergoes conditioning, whereby he or she receives high-dose chemotherapy or radiation to destroy any existing cancer cells, destroy existing bone marrow to make room for the transplanted tissue, and to suppress the immune system to reduce the risk of the transplant being rejected. Transplantation is generally done one or two days after conditioning has been completed.
- Autologous Stem Cell Transplant – Harvesting and transplanting one’s own stem cells. This is the most common type of stem cell transplant in multiple myeloma.
- Allogeneic Stem Cell Transplant – Harvesting and transplanting stem cells from a close relative or matched, unrelated donor.
Stem cell transplant is commonly used in patients diagnosed with multiple myeloma, and can be performed more than once. However, not every multiple myeloma patient is a candidate for stem cell transplantation and eligibility is done on a case-by-case basis, based upon the patient’s age and health.
RELAPSED OR REFRACTORY MULTIPLE MYELOMA
As noted previously, multiple myeloma is not curable and the goal of treatment is to get the patient into a remissive state, while monitoring and managing the complications associated with the disease. As such, it is expected that patients will eventually relapse, thereby requiring additional treatment. Additionally, there are patients who respond poorly, or not at all, to initial treatment. Initial treatment is defined as initial chemotherapy at the time of initial diagnosis, or initial chemotherapy at the time of relapse. As such, patients who responded to initial chemotherapy upon initial diagnosis and achieved remission can still become refractory to treatment, if they fail to respond to initial chemotherapy at relapse. These patients are characterized as having refractory multiple myeloma, which is more difficult to treat.
Treatment is the same for relapsed or refractory patients, as for patients receiving an initial diagnosis of multiple myeloma. This is inclusive of a second, or even third, stem cell transplant if the patient is eligible.
One area worth mentioning, in the realm of multiple myeloma, is clinical trials. In patients who are difficult to treat, or unable to tolerate current therapies, a clinical trial may be a viable treatment option. Clinical trials provide a valuable resource to the multiple myeloma community, and to the healthcare industry as a whole, in that new medications, different combinations of current medications, and use of current medications not currently tested or approved for use in a specific disease, can be tested for safety and efficacy. The hope and ambition for multiple myeloma treatment is to find a cure.
Next week will be the conclusion of this 5-part series; it will cover how to address treatment complications.