Multiple Myeloma: Comparing Treatment Options

Multiple myeloma is a cancer of plasma cells. Plasma cells are a type of white blood cell made in your bone marrow. There is no single "best" treatment. Your team chooses from several drug types. Some patients also get a stem cell transplant. The choice depends on your age, your fitness, and how your myeloma behaves. This page lays out the main options side by side. Use it to ask sharper questions.

Some people are diagnosed before myeloma causes any problems. NCI calls this smoldering multiple myeloma. It may be found when a blood or urine test is done for another reason. NCI says patients without signs or symptoms may not need treatment. They can have watchful waiting. That means close monitoring until signs or symptoms appear or change. Ask your team how often you will be monitored. Also ask what change would prompt starting treatment.

Proteasome inhibitors — bortezomib, carfilzomib, and ixazomib block a process cancer cells use to clear out damaged proteins. The proteins build up and may cause the cell to die.

Monoclonal antibodies — daratumumab and elotuzumab are lab-made immune proteins. They attach to myeloma cells. NCI also lists isatuximab for myeloma that has come back.

Immunomodulators — thalidomide, lenalidomide, and pomalidomide are listed by NCI as immunomodulators used in myeloma.

Corticosteroids — NCI says steroids have anti-tumor effects in myeloma. NCI lists dexamethasone and prednisone alongside the other drug types.

BCL2 inhibitor — venetoclax blocks a protein that helps some cells survive. NCI describes it as being studied for myeloma that has come back or stopped responding. It is not a standard part of first treatment.

NCI's treatment phases list several of these drug types together. Your team picks the combination. Ask which one is planned for you and why.

NCI splits people with symptoms into two groups. One group is younger, fit patients who can have a stem cell transplant. The other is older, less fit patients who cannot. NCI says people younger than 65 are usually considered younger and fit. People older than 75 are usually not eligible. For ages 65 to 75, fitness depends on overall health and other factors.

For the first group, NCI describes consolidation. High-dose chemotherapy is followed by a stem cell transplant. It follows an early period of drug treatment called induction. The stem cells are often your own, from your blood or bone marrow. NCI also lists donor stem cells. This is a decision to make with your specific health picture in mind.

CAR T-cell therapy changes your own T cells in a lab so they attack myeloma cells. Then they are given back by infusion. FDA labels say the approved CAR T products are for adults whose myeloma has come back or stopped responding after earlier treatments. The number of earlier treatments required depends on the product. This process takes more steps than standard chemotherapy. Ask your team whether you qualify.

NCI says maintenance therapy is often given after the first treatment to help keep the disease in remission longer. NCI lists lenalidomide, steroids, bortezomib, ixazomib, and daratumumab among the options being studied for this use. Maintenance is still real treatment, with its own side effects worth discussing.

NCI says myeloma may not respond to treatment, or may come back after treatment. If this happens, NCI lists these options:

• A different treatment than you had before, if the myeloma kept growing during treatment.
• The same drugs used before, if the relapse comes one or more years after first treatment.
• Watchful waiting, if the disease is stable.
• Monoclonal antibodies, proteasome inhibitors, immunomodulators, chemotherapy, or steroids.
• A clinical trial of CAR T-cell therapy, selinexor, or venetoclax.

Myeloma and its treatment can lower your white blood cells.

• Call 911 or go to an emergency department if you have trouble breathing, chest pain, sudden confusion, or you are hard to wake. Do not drive yourself.
• Call your care team right away, day or night, if you have a temperature of 100.4°F (38°C) or higher, chills, a sore throat, mouth sores, burning when you urinate, or redness where a catheter enters your body. A normal temperature is not a reason to wait. CDC says to call your doctor immediately for a fever during chemotherapy. According to NCI, an infection during cancer treatment can be life threatening and needs urgent medical attention. If you cannot reach your team, go to the nearest emergency department.
• Call your care team within a day or two if you have new bone pain, bones that break easily, easy bruising or bleeding, weakness in your arms or legs, or you feel very tired. NCI lists these as possible signs of myeloma and says to check with your doctor.

• Which drug combination are you recommending for me, and why this one over others?
• Am I a candidate for stem cell transplant, and what would that involve?
• What side effects should I expect from my specific combination, and which need a call right away?
• If this treatment stops working, what would we try next?

• National Cancer Institute — Multiple Myeloma and Other Plasma Cell Neoplasms Treatment (PDQ)
• National Cancer Institute — Drugs Approved for Multiple Myeloma
• FDA labels via DailyMed — Carvykti and Abecma
• CDC — Watch Out for Fever
• National Cancer Institute — Infection and Neutropenia during Cancer Treatment