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Myeloma first treatment
Myeloma is not usually considered a curable disease. Instead, it is a disease that shifts between phases of remission (when cancer cells are no longer detected or reduced) and relapse (when cancer cells have returned or increased).
Page updated 2 Aug 2021
Phases of remission, sometimes called ‘plateau phases’ can vary considerably in length of time between different people. Usually, people respond well to first-line therapy, and this period tends to be when most people experience the longest remission.
Unfortunately, people with myeloma will usually relapse after this first period of remission, but when this is the case there will be other treatment options available to you.
First-line therapy means the first time you have treatment for your myeloma. It aims to put you into a period of remission.
There are two stages involved in first-line therapy - remission induction (which aims to put you into a remission) and then consolidation therapy (which aims to keep you in remission).
Phase 1: Remission induction
The aim of remission induction (or induction therapy) is to remove as many of the myeloma cells as possible from your bone marrow. You may be given chemotherapy, steroids, targeted therapy drugs, or a combination of these.
Chemotherapy, steroids and biological therapies
Chemotherapy is directly toxic to cancer cells. Steroids are toxic to cancer cells too, but steroids can also increase the cancer-killing effects of the chemotherapy. Targeted therapies aim to help the body itself to attack or control the growth of cancer cells. The exact drug, dose and combination you’ll be offered will depend upon your general health and fitness and whether a stem cell transplant is part of your treatment plan.
In general, if you are fit enough and your healthcare team think it’s appropriate for you, you may have high doses of a drug or combination of drugs. You can then have a stem cell transplant as your consolidation therapy afterwards.
If the doctors think a stem cell transplant is too risky for you, you’ll have drugs in standard doses, again aiming to put you into a remission. You'll have other drugs for your consolidation therapy afterwards.
Remission induction is usually given in cycles. One course of treatment can include four to six cycles, with each cycle lasting for three to five weeks. Overall, remission induction can last four to six months.
The most common drugs prescribed are listed below. All are taken by mouth (orally), unless stated otherwise.
- melphalan (Alkeran®)
- bortezomib (Velcade®) − injected under the skin (subcutaneously)
- lenalidomide (Revlimid®)
- pomalidomide (Imnovid®)
- daratumumab (Darzalex®) either injected under the skin (subcutaneously) or by a drip into a vein intravenous infusion).
The most common combination used in first-line therapy for people fit enough to tolerate it is VTD (Velcade-thalidomide-dexamethasone). Velcade is the trade name for bortezomib. This treatment can be given before a stem cell transplant.
Less fit people will be offered lenalidomide and dexamethasone, or VMP (Velcade-melphalan-prednisolone). These drug combinations will not usually be followed by a stem cell transplant.
Alternative treatment options during the covid-19 pandemic
Lenalidomide and dexamethasone may be offered as an alternative first line treatment while the coronavirus (COVID-19) pandemic continues. This is because whereas bortezomib (Velcade) is injected, lenalidomide is taken by mouth (orally), so may involve spending less time in hospital. However, many hospitals now allow patients to self-administer bortezomib, which also reduces hospital exposure.
This interim treatment option is recommended by NICE, whose guidance is for healthcare in England, but may be (and often is) adopted in other countries of the UK too.
Read our information on coronavirus and your blood cancer treatment.
There is evidence that the drug thalidomide can affect the development of babies in the womb. Women who may be pregnant should not take any combination of drugs which includes thalidomide or similar drugs such as lenalidomide and pomalidomide.
While you are taking these drugs, you must use condoms or another barrier method of contraception. This is important for men as well as women, as thalidomide is present in the sperm of men taking it.
To avoid any risk to unborn babies, if you're taking thalidomide or similar drugs, you shouldn’t donate blood and must make sure no one else has access to your medication.
Thalidomide, lenalidomide and pomalidomide all increase the likelihood of developing blood clots, where the blood thickens and can cause blockages in the blood vessels. So if you take these drugs you will also be given medication such as low molecular weight heparin (LMWH) or aspirin to thin your blood and reduce the risk of clotting. LMWH is injected daily under the skin and aspirin is taken as a tablet.
Phase 2: Consolidation therapy
If after your initial treatment the paraprotein has gone, it’s called a complete response. If you have a complete response, you’ll still be considered for further treatment or consolidation therapy. This is because without the consolidation, the myeloma may quickly come back.
Consolidation therapy tends to involve either a stem cell transplant or a further combination of drugs.
Stem cell transplant
A stem cell transplant (sometimes called a bone marrow transplant) aims to give you healthy stem cells, which then produce normal blood cells. There are two main types of stem cell transplant:
- autologous or autograft – this uses your own stem cells
- allogeneic or allograft – this uses donor stem cells and is a higher risk procedure.
People with myeloma typically have autologous transplants, not allogeneic ones. You might also hear an autologous transplant called an auto-SCT. Occasionally allogeneic stem cell transplants might be considered for fitter people with a particularly aggressive type of myeloma.
It’s likely that you’ll take melphalan (a chemotherapy drug used to slow the growth of cancer cells) before your stem cells are returned to your body. The melphalan removes any remaining myeloma cells and prepares your bone marrow to receive the stem cells. This is called conditioning.
For more information on stem cell transplants, download or order our booklet: The seven steps: blood stem cell and bone marrow transplants.
New treatments to extend remission after a stem cell transplant
In 2020 in Scotland, and in 2021 in England, Wales and Northern Ireland, a drug called lenalidomide was approved for people to have after their stem cell transplant.
For people newly diagnosed with myeloma, who can have a stem cell transplant as part of their first treatment, lenalidomide can be given after the transplant as a maintenance treatment. Previously, people stopped treatment after their transplant, and were monitored for signs of progression. But in clinical trials, continuing on lenalidomide increased the length of remission before relapse and improved overall survival.
Lenalidomide will be suitable for most people who are newly diagnosed with myeloma and have a stem cell transplant as part of their initial treatment. Lenalidomide is targeted therapy drug (not a chemotherapy) that is taken as a tablet.
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