Multiple Myeloma Treatment: Why It’s So Diverse

Introduction:

While multiple myeloma only makes up about 1% of all cancer diagnoses, its wide-reaching & vast impact on our patients’ lives is significant. Many of these patients will be on & off cancer treatments over a long period, causing many side effects.

Many PTs are unsure of treating these patients, so we’re diving headfirst into the medical treatment of multiple myeloma & what this means for our patient care.

Two main categories Of multiple myeloma

Smoldering myeloma (asymptomatic)

Patients with smoldering myeloma are classified into either low-risk or high-risk categories, based on how likely it is they will progress to symptomatic MM. 

Patients with low risk smoldering myeloma may undergo clinical trial treatment or observation.

Patients with high-risk smoldering myeloma may actually undergo a very similar protocol to low-risk or they may actually begin lenalidomide if they meet certain criteria.

Patients will be reassessed periodically to determine if there’s been any progression to symptomatic myeloma and then will undergo the treatment protocol for symptomatic multiple myeloma.

Symptomatic multiple myeloma

Once a patient is diagnosed with symptomatic multiple myeloma, they will initiate therapy and some kind of bone-targeting treatment. Depending on the patient’s symptoms, they may also begin some kind of supportive care treatment. 

It’s critical that these patients beginning therapy immediately because of how aggressive multiple myeloma can truly be. Patients will then be assessed to determine if they’re a candidate for a hematopoietic stem cell transplant.

Throughout the primary treatment, patients will be monitored for their treatment response: either the multiple myeloma responded to treatment OR they had progression of their disease.

If the patient had a response to primary therapy, they may undergo a hematopoietic stem cell transplant or they may continue on some kind of maintenance/continuous therapy.

Multiple Myeloma is Incurable

Like we discussed in Ep. 202, multiple myeloma is a progressive, incurable disease. This means that treatment aims to get the patient into a disease-free state and keep them there as long as possible.

But the fact is, multiple myeloma will come back at some point.

And when multiple myeloma does come back, the patient will undergo another round of treatment. This could continue for multiple rounds of treatment, remission, treatment, remission, etc.

At some point, patients with multiple myeloma may be considered for CAR T-Cell Therapy, but this is a later line therapy.

This may change in the coming years, but right now CAR T-cell therapy is only approved for later line treatment for multiple myeloma.

Specific agents for multiple myeloma treatment

The preferred treatment regimens for multiple myeloma are very similar between patients who are transplant candidates and those who are not candidates for hematopoietic stem cell transplants.

Regimens usually include some cocktail of bortezomib, lenalidomide, and dexamethasone.

Now we know that every patient is different, so there may be certain scenarios in which patients are undergoing different treatments with different agents.

For patients on maintenance therapy for multiple myeloma, the agents are very similar. Many patients will be treated with lenalidomide.

When the patient experiences progression or relapse is, the agents they are on will likely change.

Is radiation therapy used to treat multiple myeloma?

Generally, radiation therapy is used for palliative purposes in multiple myeloma (maybe for bony lesions, etc.).

Other treatments patients with multiple myeloma may undergo

Patients with multiple myeloma can be experiencing other conditions.

Remember:

  • C = elevated calcium
  • R = renal failure
  • A = anemia
  • B = bony lesions

Patients may need treatment for some or all of these complications of multiple myeloma.

For patients who have bone disease, they may be treated with bisphosphonates or denosumab.

Oncologic emergency ALERT!

Patients with multiple myeloma are at an increased risk of developing some kind of venous thromboembolism especially in the first six months after their diagnosis.

Special multiple myeloma risk factors for VTE:

  • Immunomodulatory drugs (lenalidomide, for example)
  • Dexamethasone
  • Also general other risk factors: immobility, active cancer diagnosis/treatment, etc.

Conclusion:

Multiple myeloma can sometimes be a confusing diagnosis to work with.

No matter your experience with multiple myeloma so far, it’s likely that you’ll encounter one of these patients at some point in your career. And these patients are going to need YOUR skilled physical therapy services.

Closing:

So now I want to hear from you: what did I miss? What else would you include in this episode about multiple myeloma? Message me on Instagram and let me know.

Until next time this is Elise with TheOncoPT.  And remember you are exactly the physical therapist that your patients with cancer need. So let’s get to work.

References:

https://www.nccn.org/professionals/physician_gls/pdf/myeloma.pdf

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