Multiple myeloma treatment (treatment options)
Multiple myeloma is a complex disease with a difficult treatment, and there are many limitations in the current therapeutic protocols. When treating a patient with multiple myeloma, the goal of therapy is to obtain the best possible result in the first try. When this is the case, the patient’s survival rate improves considerably. However, it requires a complete understanding of the natural history of the disease and choosing the best treatment for each patient and their phase of the disease.
Treatment is focused on slowing down the disease process and treating the complications associated with multiple myeloma. We need to remember that multiple myeloma is incurable, but proper treatment and specific modalities offer the best results. There is even a slight chance of cure and complete disappearance of M protein in the blood, which only happens in 3% of the cases. Some treatment protocols are instrumental, but they can cause severe side effects, including new malignancies.
Most patients with multiple myeloma undergo chemotherapy as a part of their induction therapy, which is the first phase of the treatment followed by maintenance therapy. But there are many other options and procedures. In short, these are the leading methods to treat multiple myeloma:
Chemotherapy and immunotherapy
Chemotherapy is required for all patients with symptomatic multiple myeloma, but not in asymptomatic cases. As chemotherapy and immunotherapy are applied, it is essential to measure the M protein, which helps doctors evaluate if the treatment is doing as it should. The goal is to achieve a reduction of 50% in M protein levels.
The type and intensity of chemo and radiotherapy depend on whether or not the patient is eligible for a transplant. So, it is broken down into three categories: young and healthy patients who can be transplanted, high-risk patients who can be transplanted, and elderly patients who cannot be transplanted.
A 4-day regime is often chosen in young and healthy patients, including intravenous vincristine, doxorubicin, and dexamethasone. This therapy is also known as VAD, and it is followed by 4 days of oral dexamethasone. Other regimens also use lenalidomide, thalidomide, bortezomib, or daratumumab.
In high-risk patients who are candidates for transplant, novel agents are commonly used instead of VAD therapy. These patients have a very high tendency of relapse and need lenalidomide, thalidomide, or bortezomib as a part of their treatment, followed by stem cell transplantation.
Finally, elderly patients who are not candidates for transplants typically use melphalan and prednisone for 4 days, repeated every 4-6 weeks for one year. However, there are many other regimes with combinations of dexamethasone with daratumumab, bortezomib, lenalidomide, or cyclophosphamide, depending on each case.
Radiation therapy may also be used, but mainly to reduce the risk of fracture and treat the spinal cord’s compression. It is only used if the bone pain is mild, and if 50% or a lower proportion of the bone is compromised by multiple myeloma.
It is usually performed with bone marrow from the same patient or stem cells from the patient’s peripheral blood. Doctors harvest stem cells from the patient and irradiate the whole body to destroy the bone marrow’s defective bone marrow. This is followed by a reinfusion of the stem cells or bone marrow. Only a few patients may receive bone marrow from someone else, but it is not the standard procedure, and several tests should be performed, except for twin donors.
According to recent research, interferon-alpha can be used to prolong remission in high-risk patients. In other words, it delays the reappearance of multiple myeloma when the chance of such an event is very high.
Bone and skeletal therapy
Besides radiation therapy, we can also use other substances to promote skeletal health and reduce fractures’ risk. For example, bisphosphonates are useful to inhibit the activity of osteoclasts.
Therapeutic options for other complications
Depending on the complications and the symptoms of each patient, a set of drugs and therapeutic options can be used. For example, erythropoietin in anemia, pins to stabilize pathologic fractures, corticosteroids, and spinal cord compression surgery.
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