There's Hope for Myeloma Patients Who Can't Have Transplants

Brought to you in partnership with the Multiple Myeloma Research Foundation

For years, the standard treatment for multiple myeloma — at least for patients younger than 65 — has involved removing blood-forming stem cells from the patient’s bone marrow or bloodstream, then using high-dose chemo to kill off the myeloma cells. Afterward, the stored stem cells are infused back into the patient, where they aid in recovery.

Although transplants remain the best option for patients younger than 65, they are not an option for all patients.

Because transplants carry substantial risks, they aren’t usually done in older or sicker patients.

So what happens when you are ineligible?

For newly diagnosed myeloma patients, initial treatment usually consists of induction, or front-line therapy, which is meant to decrease disease burden to a very low or even undetectable level.

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Induction therapy choices (3-4 cycles of therapy):

3 drug regimens, including Revlimid-Velcade-dexamethasone,
Darzalex-Revlimid-dexamethasone
Revlimid-Velcade-dexamethasone lite (a lower dose of this common triplet regimen, used for frail patients)
A 2 drug regimen such as Revlimid-dexamethasone may be considered for frail patients
A clinical trial

Transplant-ineligible patients go directly from induction therapy of varied length to consolidation or maintenance therapy, depending on their response to induction therapy. Your care team can help decide which course of therapy is best for you, based on your myeloma subtype and treatment goals.

Maintenance Therapy

After induction, patients will either undergo observation without treatment (less common) or maintenance (continuous) therapy with an approved myeloma agent. Maintenance therapy has been shown to improve progression-free survival (it can increase the length of time the patient spends in remission before they relapse) but is also associated with treatment side effects. Revlimid is an approved maintenance therapy option, but there are also clinical trials underway to study Ninlaro, Velcade, Kyprolis, Darzalex and Empliciti as maintenance therapy options.

Treatment

Once patients have achieved a response (decrease in disease burden and decreased signs and symptoms of myeloma) with front-line therapy (induction, stem cell transplant and maintenance), they are closely followed by their care teams to watch for signs of relapse (loss of response to their current drug regimen) and reappearance of myeloma signs and symptoms. There are many very effective treatment options for relapsed patients, and many more being tested in clinical trials, so having a relapse should not cause loss of hope for a favorable outcome. The choice of the next therapeutic option may rest on when the relapse takes place.

Therapy choices for a first relapse that occurs less than 6 months after front-line therapy:

Different therapy
Autologous stem cell transplant
Clinical trial
Repeat initial therapy
Different therapy
Autologous stem cell transplant
Clinical trial

Therapy choices for second-line therapy may include the following drugs in combination with a steroid (dexamethasone or prednisone):

Velcade
Revlimid
Kyprolis
Empliciti
Ninlaro
Darzalex

If an early response is not achieved with a second-line combination therapy, or when a patient has a relapse from second-line therapy, a third drug may be added:

Pomalyst
Farydak
Sarclisa
XPOVIO

Patients should also consider a clinical trial at any point in their disease journey. There are many new agents and immune therapies under investigation which may provide treatment benefits to relapsed/refractory patients. Your care team can help you find an appropriate trial. You can also use our clinical trial finder or speak with an MMRF patient navigator for more information.

By Blackdoctor | Published November 8, 2021