Treatment for Multiple Myeloma
Each patient's care combines the most advanced knowledge currently available with innovative new therapies based on discoveries made through research at the Jerome Lipper Multiple Myeloma Center laboratories.
Treatments can include:
Watchful Waiting
Patients who are not experiencing symptoms or who have precursor conditions — smoldering multiple myeloma (SMM) or monoclonal gammopathy of undetermined significance (MGUS) — may not need treatment and can be monitored for disease progression. It's important to note that almost 70 percent of MGUS patients do not progress to multiple myeloma or another disorder. And while the percentage of patients with SMM who may progress to multiple myeloma is higher than with MGUS, not everyone with SMM develops multiple myeloma, either.
Disease-Modifying Therapies
Our Center for Early Detection and Interception of Blood Cancers (formerly the Center for Prevention of Progression) cares for patients diagnosed with – or at high risk for – precursor conditions of multiple myeloma such as MGUS and smoldering myeloma. The clinic works with patients to manage their risk of disease progression and offers clinical trials of early interventional therapies to prevent disease progression.
Our researchers are studying the genomic, genetic, and epigenetic factors that characterize precancerous conditions, such as smoldering multiple myeloma and monoclonal gammopathy of undetermined significance, at our Center for Early Detection and Interception of Blood Cancers.
We created the center to understand, at the molecular level, why some patients go on to develop disease, while others do not – and to develop non-toxic targeted therapies to prevent progression, or even eliminate the disease before it leads to symptoms.
Induction Phase of Treatment
Most people with multiple myeloma receive a combination of three or four drugs that may include a CD38-targeted monoclonal antibody, such as daratumumab; an immunomodulatory drug (IMID), such as lenalidomide; a proteasome inhibitor such as bortezomib; and a corticosteroid such as dexamethasone. In a recent Phase II clinical trial, the combination of daratumumab, lenalidomide, bortezomib, and dexamethasone (also called Dara-RVD) was superior to a three-drug combination of lenalidomide, bortezomib, and dexamethasone (also called RVd) in terms of duration of response to treatment, as well as depth of response. These findings confirmed the effectiveness of this approach to treatment.
A three- or four-drug combination that includes an alkylating drug such as cyclophosphamide, along with a CD38-monoclonal antibody such as daratumumab, a proteasome inhibitor such as bortezomib, and corticosteroid can also be used as an induction regimen.
People who are frail due to advanced age or other medical conditions may receive only two or three drugs in order to decrease the likelihood and severity of chemotherapy-related side effects.
Induction chemotherapy is typically administered over a period of four to eight months, and is followed by either treatment intensification with high-dose chemotherapy and autologous stem cell transplantation or maintenance therapy. Many factors are considered in determining whether or not to pursue transplant, including your age, frailty, other medical conditions that may impact suitability for transplant, response to and tolerance of induction chemotherapy, and your own preferences and goals of care.
Maintenance Therapy
After the initial treatment, maintenance therapy is often used to help keep the disease in remission for a longer time.
Several clinical trials have shown a clear benefit for maintenance therapy in terms of the duration of response to treatment and long-term outcomes for patients. Most of these trials have incorporated lenalidomide as the chemotherapeutic agent of choice. On the strength of these results, the FDA approved lenalidomide for maintenance therapy following stem cell transplantation.
After a Stem Cell Transplant
- People who undergo stem cell transplantation typically start maintenance therapy three to four months after the transplant. In our practice, lenalidomide is usually given once a day for three weeks followed by a week off, or daily continuously.
- We continue maintenance therapy until the time the disease progresses, as long as you are tolerating it well.
Without a Stem Cell Transplant
- For people who do not undergo stem cell transplantation immediately, maintenance therapy typically starts after the induction phase of therapy or after the stem cell collection process.
- We most often use lenalidomide as maintenance therapy, although there are other options, including ongoing administration of a proteasome inhibitor, such as bortezomib or carfilzomib.
Relapsed Disease
At some point, nearly all people with multiple myeloma experience progression of their disease. When your disease relapses, your team will evaluate treatment options, including additional chemotherapy, novel immune therapies such as bispecific antibodies, or a cellular therapy such as CAR T-cell therapy.
Fortunately, there is a large and expanding number of effective treatment options available. The last two decades have seen impressive advancement in the field, with 13 new drug approvals by the FDA in multiple myeloma treatment. Our Center has played a lead role in the development of many of these treatments.
- You will have the opportunity to speak with your physician about which regimen is most appropriate for you.
- Treatment decisions will take into account prior treatment you have received, the effectiveness of these treatments, side effects that you have experienced, and your preferences for treatment.
- Once treatment starts for relapsed disease, you will be monitored closely to evaluate how the treatment is working. Adjustments are made to enhance its effectiveness and in relation to how well you tolerate the therapy. Treatment generally continues until your disease progresses, provided you tolerate treatment well.
- Under certain circumstances, therapy could be stopped and you may be observed without treatment.
Supportive Therapy
Many patients with multiple myeloma experience high rates of musculoskeletal events. To help strengthen patients' bones, we often include supportive therapy as part of the treatment plan. Supportive care may include various therapies to strengthen bones, reduce bone pain, and slow bone loss. Patients with multiple myeloma are also at greater risk for infection. Your team will provide a plan to prevent, minimize, or treat infection.
Your Care
All outpatient therapy is provided at the Yawkey Center for Cancer Care at Dana-Farber Cancer Institute, one of the most advanced outpatient cancer centers in the country.
If you need to be hospitalized during your care, or if you undergo stem cell transplantation, you will be admitted to Brigham and Women's Hospital (BWH) or the Dana-Farber Inpatient Hospital located within BWH. Your medical oncologist and nurse will closely monitor your care and will coordinate your care with additional specialists who will address any other symptoms you may be experiencing. Learn more about your stay.
If radiation therapy is part of your care plan, our Radiation Oncology department has two separate units, one at Brigham and Women's Hospital and the other at Dana-Farber.
Survivorship Care
We follow our patients closely between treatment plans while you are in remission. Nurses and nurse practitioners will carefully monitor the results of your lab tests and will stay in close contact with you in person and by phone, to explain options and treatments, and to help you manage side effects.
Our Adult Survivorship Program helps you find expertise, education, and support to manage issues related to surviving cancer.
