Multiple Myeloma Treatment
At MD Anderson, we offer multiple myeloma patients the most advanced treatments along with a range of clinical trials (research studies) of newer drugs and therapies. Our myeloma experts work closely together and with you to develop the most effective treatment plan, while focusing on your quality of life.
While treatments usually do not cure multiple myeloma, we can improve the quality of life and health of many patients by decreasing the disease and its symptoms for extended periods.
Advanced Treatment Options
The standard approach to newly diagnosed multiple myeloma is frontline chemotherapy for a few months, followed by high dose chemotherapy and a stem cell transplant (also known as stem cell rescue), then maintenance therapy, which entails lower doses of chemotherapy. MD Anderson is among a select few centers that are pioneering newer options which will hopefully improve outcomes. Many patients have had remarkable success.
These options include immunotherapy to help your body fight the cancer and new methods for stem cell transplantation. In addition, we are actively pursuing ways to reduce the symptoms and side effects of multiple myeloma and its treatments. For instance, we were instrumental in finding that multiple myeloma patients taking bisphosphates are less likely to have bone-related events, such as breaks.
Multiple Myeloma Treatments
If you are diagnosed with multiple myeloma, your doctor will discuss the best options to treat it. This depends on several factors, including the type and stage of the cancer and your general health.
Your treatment for multiple myeloma will be customized to your particular needs. One or more of the following therapies may be recommended to treat the cancer or help relieve symptoms.
Multiple myeloma chemotherapy
Chemotherapy is the usual starting point in treating multiple myeloma. MD Anderson offers the most up-to-date and advanced chemotherapy options.
Immunotherapy
MD Anderson is among just a few cancer centers in the nation that are able to offer targeted therapies for some types of multiple myeloma. These innovative new drugs stop the growth of cancer cells by interfering with certain proteins and receptors or blood vessels that supply the cancer with what it needs to grow.
Possibilities may include:
- Monoclonal antibodies, including Darzalex (daratumumab) and Empliciti (elotuzumab)
- Chimeric antigen rector T cells (CAR T cells) which are genetically modified T cells which fight the myeloma directly
- Bispecific t cell engagers which help activate and get your own immune cells next to myeloma cells in your body to kill them
- Cytokine therapies
- Vaccine therapy
Multiple myeloma radiation therapy
Radiation therapy often plays a valuable role in providing quick pain relief and decreasing the risk of fractured bones. It can also attack soft tissue collections of myeloma cells (plasmacytomas) that may threaten neurologic function by compressing the spinal cord or various nerves. In rarer instances, plasma cell tumors will present in one location (solitary plasmacytoma). In these situations radiation therapy alone is often used as the primary treatment.
A typical radiation treatment plan for a patient with multiple myeloma includes five sessions a week for approximately two weeks. Despite the lower doses of radiation therapy that are utilized to treat patients with multiple myeloma, it is still essential that radiation therapy is administered in a targeted way to minimize radiation exposure to surrounding normal tissues. This is accomplished through the utilization of computed tomography (CT) scan based radiation planning, immobilization devices to minimize patient movement during treatment and modern radiation planning techniques that permit focused radiation delivery, such as intensity modulated radiation therapy (IMRT), volumetric arc radiation therapy (VMAT) and proton radiotherapy.
Our Radiation Oncology Center treats more than 100 multiple myeloma and plasmacytoma patients each year, with a team of four skilled radiation oncologists who specialize in the management of patients with hematologic malignancies. Our ultimate goal is to administer effective, safe, modern radiation therapy while limiting toxicity.
Multiple myeloma stem cell transplants
A stem cell transplant replaces defective or damaged cells in patients whose normal blood cells have been affected by cancer. If a stem cell transplant is needed, MD Anderson has one of the most active and advanced programs in the nation.
Multiple myeloma plasma exchange
High levels of abnormal proteins can lead to thickening of the blood. Plasma can be removed and replaced with normal plasma from a healthy donor. This can quickly relieve symptoms of increased blood thickness until chemotherapy/immunotherapy has a chance to destroy the multiple myeloma cells that produce the abnormal protein.
Watchful Waiting
The watchful waiting approach involves closely monitoring multiple myeloma without active treatment. It is recommended for patients with asymptomatic (smoldering) myeloma or monoclonal gammopathy of undetermined significance (MGUS).
After completing a course of treatment, there are few words that sound better to a patient than “complete remission.” It’s an indication that the treatment has worked, and there is no evidence of cancer based on scans or lab tests.
However, there is a different phrase that can be somewhat confusing to patients – minimal residual disease (MRD). This term is used often by physicians when treating patients with blood cancers, such as leukemia, lymphoma or multiple myeloma.
MRD refers to cancer cells remaining after treatment that can’t be detected by those same scans or tests. But what exactly does it mean for patients?
To learn more about minimal residual disease, we spoke with leukemia specialist Ghayas Issa, M.D., of MD Anderson’s Myelodysplastic Syndromes (MDS) and Acute Myeloid Leukemia (AML) Moon Shot® team. Here’s what he shared.
How do you explain minimal residual disease to patients?
Minimal residual disease is a small number of cancer cells left in the body after treatment. These cells have the potential to come back and cause relapse in our patients.
In leukemia, for example, we look for response after chemotherapy treatment by looking under the microscope for cancer cells present in a bone marrow biopsy. When there are no cancer cells present, and the bone marrow is making normal cells, we call that a complete response.
However, we know that if we don’t do further treatment, a portion of these patients will experience a relapse. That means there were some leukemia cells hiding that we weren’t able to detect under the microscope. That is minimal residual disease, or perhaps a better term is measurable residual disease. Typically, these cells don’t cause any symptoms, but they have the potential to lead to a relapse.
If we can’t detect minimal residual disease under the microscope, how do we test for it?
We now have much more sensitive assays available to us that allow us to quantify MRD. These could include next generation genetic sequencing, where we can analyze bone marrow samples for genetic mutations. If there are mutations present, that means there is minimal residual disease, even though we can’t see anything under the microscope.
We can also use a technique called flow cytometry, which allows us look in the same samples for abnormal proteins on the surface of cells. By determining how many cells have abnormal proteins detected, we can get a better sense of residual cancer cells. Using these new assays, we routinely try to quantify whether a patient has MRD following standard treatment.
What are the implications for a patient who has evidence of minimal residual disease after treatment?
That’s difficult to say, because it’s not the same across all types of blood cancers. Some patients with MRD will have different responses than others. In general, if a patient has MRD, we need to do additional treatments to work toward the best outcome. If we do nothing, we know that the residual cells will cause a relapse.
It also depends on the timing of the MRD test. In my leukemia patients, if there is MRD after the first cycle of chemotherapy treatment, it tells me that I probably need to give more treatment — either a different medication or a different course of treatment. If there is still MRD after many rounds of chemotherapy, that is an indication that the patient may need to have a stem cell transplant, when otherwise it might not have been appropriate.
Ultimately, MRD is a marker that we need to be more aggressive in our treatment to try and prevent the cells from coming back.
What can cancer researchers learn from the residual cancer cells?
We can learn a great deal. These cancers can adapt to treatment, meaning the cancer we start with is not the same as what we have after treatment. By studying the minimal residual disease, we can learn more about what is left after treatment.
That helps us to do several things. First, it allows us to modify our treatment, either by adding medications that target specific vulnerabilities in the cancer cells, including medications that are especially good at killing even residual cells, or doing a stem cell transplant, which is able to take care of residual cells.
Currently, I work with a wonderful team through the MDS and AML Moon Shot to study these residual cancer cells in order to find new vulnerabilities. Through our research, we’re hoping to identify new treatments that we can use in the future to specifically eliminate minimal residual disease.
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