Multiple myeloma: When to treat and when to wait

Multiple myeloma is a cancer that develops in a type of white blood cell called plasma cells. Normally, these cells help us make antibodies to fight infection. But when something goes wrong during cell division, they can live forever.

Some patients live with multiple myeloma for years without any negative effects. This is called smoldering myeloma. But eventually the myeloma cells can make things go haywire in the body, affecting patients’ red blood cell counts, the kidneys, calcium levels and even the bones.

To understand how multiple myeloma affects the body and when it’s best to treat it, we talked with Krina Patel, M.D.

How does multiple myeloma affect the body?

One common issue related to the myeloma cells is anemia. Often the cancerous cells take up so much space in the bone marrow that they push the red blood cells out.

Myeloma can also damage the kidneys. It can cause inflammation and block the filters of the kidney, so some patients may notice foam or bubbles in their urine.

Some patients also experience bone issues. Myeloma can cause lytic lesions, which are like holes in the bones. The myeloma cells can also cluster in or just outside the bone and form tumors called plasmacytomas. The cancer accelerates osteoporosis as well by helping the cells that break down bone and slowing the cells that build new bone.

Although it's rare, the tumor-like plasmacytoma can also occur elsewhere in the body, like the lungs or the liver, but that typically occurs with more advanced disease. This is called extramedullary disease.

Most patients don't experience all these issues – usually one or two.

Why does timing matter when treating multiple myeloma?

Myeloma isn't curable yet, but it's very treatable. The key is deciding when to treat it to manage the symptoms. Our goal is to improve the patient’s quantity of life without compromising quality of life.

Anemia can cause fatigue. Bone issues can cause fractures, so it’s harder to walk. Kidney failure will require you to go on dialysis. All of this impacts quality of life. But if we treat the disease too early, it can become resistant to treatment and ultimately decrease your lifespan.

Our goal is to put the myeloma into hibernation for as long as we can. And then we will treat you again when we think that it's about to cause more problems.

How is multiple myeloma initially treated?

75% of patients have standard-risk disease, which is myeloma that we think will respond to treatment well. Although radiation therapy and surgery are used in some rare situations, patients typically receive three or four rounds of chemotherapy. However, the chemotherapy we use to treat multiple myeloma is different than what’s used for other cancers. The side effects aren’t as severe, and we try to limit the impact on your daily routine. Patients may come into the clinic once a week for a 30-minute chemotherapy infusion or a shot, and then they are likely taking chemotherapy pills at home daily for a few weeks.

In addition, patients receive steroids to help with the inflammation in the bones and the kidneys. This can also help reduce pain. More importantly, steroids kill the myeloma cells.

Through blood draws, we monitor protein levels to see how the myeloma is responding to treatment. Once the myeloma protein level is down, patients typically receive a stem cell transplant. This allows us to give a big dose of chemotherapy that wipes out the bone marrow and puts the myeloma into deeper, longer hibernation.

After that, patients go on chemotherapy maintenance. Standard-risk patients receive a lower dose chemotherapy pill until the myeloma protein numbers start to rise again, which is on average about four to five years. Patients with high-risk disease have a more aggressive maintenance plan that includes a combination of chemotherapies. They typically have about two to three years until the disease flairs up again.

What happens when the myeloma returns?

Multiple myeloma is smart. Each time it comes back, it’s a bit more aggressive, but the treatment plan is similar. After using one drug as the first-line treatment, the myeloma typically learns to go around it. But studies have shown that when we use a combination of drugs (typically three) to treat relapsed disease, it tends to stay down longer.

There is a lot of research being done in myeloma, so we have new drug options that we can try when chemotherapy fails. We’re seeing an explosion of immune therapies like CAR T cell therapy, monoclonal antibodies and targeted therapies. But because we have so many options for treatment, it’s more challenging to select the right approach for each patient.

If you’ve recently been diagnosed with myeloma, I suggest you seek care in as specialty center like MD Anderson so that you have the best drugs for you, sequenced in the best order for your disease. That way, we can give you as many years possible to enjoy life without letting myeloma disrupt it.

Request an appointment at MD Anderson online or by calling 1-877-632-6789.