5 questions about multiple myeloma, answered

Many patients’ goal for cancer treatment is cure. But what if there isn’t a known cure for your diagnosis? That’s the case for patients with multiple myeloma.

Although there isn’t a cure, many patients live comfortably for years, thanks to the ever-expanding collection of treatment options.

“These days, myeloma can be managed like a chronic disease,” says multiple myeloma specialist Krina Patel, M.D. “The prognosis for multiple myeloma can be very good.”

 Some patients may receive treatment throughout their lives without much impact on their daily routine.

New therapies are changing even that – offering remission that doesn’t require long-term treatment. “There have been leaps in treatments, especially immunotherapies, in the last few years,” says Patel. 

We asked her to explain the basics of multiple myeloma, including symptoms, treatments and the latest research.

What is multiple myeloma?

Multiple myeloma is a cancer of white blood cells called plasma cells. These cells help us make antibodies to fight infection. They develop from a type of B cell. Myeloma cells develop when  something goes wrong as plasma cells divide to reproduce.

What are symptoms of multiple myeloma?

The first sign of multiple myeloma is usually bloodwork showing a high level of proteins. “At the earlier stages, patients often don’t notice anything different,” Patel says. “That can go on for years.” This is known as smoldering myeloma.

As myeloma progresses, it causes complications that show up in many ways.

“One common issue is anemia because of the amount of space myeloma cells take up in the bone marrow,” Patel says. The cancerous cells overcrowd the normal red blood cells and cause the number to drop. Patients experiencing anemia may feel fatigued and weak, and their complexion may turn pale. They may also experience shortness of breath with normal activities.

Kidney failure can be another sign of myeloma. “Some of the proteins that the myeloma makes may damage the kidneys and their ability to filter,” Patel says.

Myeloma cells can also affect the bones, causing them to become brittle and fragile. Although not common and more often seen in patients with more advanced disease, the myeloma cells can cluster outside the bones and create tumors called plasmacytomas.

Are some people more likely to develop multiple myeloma?

As people get older – above age 65 – their chances of developing multiple myeloma go up.

Multiple myeloma is twice as common in Black Americans compared to Caucasians. It’s also more common in men than women.

Also, people who’ve had prior radiation exposure are more likely to be diagnosed with myeloma, and Agent Orange exposure may also put a person at increased risk.

Finally, people with obesity are believed to be at increased risk for developing myeloma.

How is multiple myeloma treated?

When there aren’t clinical symptoms, patients may not receive treatment. Instead, they’ll be monitored closely for signs of the cancer’s progression.

That’s because the timing of treatment is sensitive. “Our goal is to treat before the myeloma cells cause organ damage, but not too early,” Patel says. Treating too early can lead to treatment resistance and negatively impact survival, she says. However, at MD Anderson, we’re looking into using immunotherapies to reduce disease levels and the risk of progression for patients with early-stage disease.

For patients experiencing symptoms, initial treatment is typically a combination of  chemotherapies, immunotherapies and a steroid.

Once the abnormal myeloma protein levels drop, a patient may receive high-dose chemotherapy to treat any remaining myeloma cells and then an autologous stem cell transplantation to revitalize the bone marrow so it can produce healthy cells again.

Initial treatment typically spans six months. After a successful stem cell transplant, a patient will start maintenance therapy. Patients will take a low-dose chemotherapy pill indefinitely to keep the protein levels down.

MD Anderson is leading multiple clinical trials to improve current multiple myeloma treatment approaches. “We’re evaluating other combination therapies in newly diagnosed patients,” Patel says. “And my colleague Melody Becnel, M.D., leads maintenance clinical trials to increase the depth of response as well as time in response for patients after autologous stem cell transplant.”

Can immunotherapy treat multiple myeloma?

Several types of immunotherapies treat myeloma. CAR T cell therapy improves a patient’s own T cells to treat cancer, and there are currently two approved for myeloma. They’re approved for patients who have already had four or more lines of therapy and are experiencing a relapse, or for cases where the disease isn’t responding to traditional treatments. This is known as refractory disease.

“The number of patients who respond to and the length of remissions seen with CAR T are better than anything we’ve seen for these patients,” Patel says. 75% to 95% of patients see their disease respond. In the case of ciltacabtagene autoleucel, which was approved in February 2022, the length of remissions last more thanf two years, Patel says.

Beyond its success in treating relapsed disease, CAR T cell therapy is changing treatment patterns because it doesn’t require maintenance therapy. “It’s amazing since for many patients, it may be the first time in years they have not taken a daily chemotherapy pill,” Patel says.

Bispecific T-cell engagers are another type of immunotherapy showing promise for patients with relapsed or refractory myeloma. “In clinical trials led by my colleague Hans Lee, M.D., response rates have been 60% or higher, and patients have been responding for over 18 months,” Patel says. She says the first standard-of-care bispecific is expected to be approved by the Food and Drug Administration (FDA) soon.

Now, many clinical trials are evaluating CAR T cell therapy and bispecifics earlier in myeloma treatment as well as using newer targets, Patel says.

“It’s a very exciting time in myeloma,” she adds. “We’ve seen amazing progress in the last few years, and patients are living longer with better quality of life.”

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