Blood cancers such as multiple myeloma are often treated with anti-cancer drugs called chemotherapy. Other therapies are often used alongside chemotherapy to treat multiple myeloma. These additional treatments include stem cell transplantation, radiation therapy, surgery, and supportive treatments.

Phases of Chemotherapy Treatment

Multiple myeloma is treated using three phases: induction, consolidation, and maintenance. Each phase has a different purpose. Doctors may recommend new medications or doses during each phase.

Induction Therapy

The initial treatments a person receives after being diagnosed with myeloma are called induction therapy, frontline therapy, or first-line therapy. The goal of induction therapy is to get the myeloma under control. These treatments should reduce the levels of cancerous plasma cells, help treat or prevent complications, and prevent early death. Myeloma induction therapy often includes “triplets” — combinations of three different drugs. Some people with myeloma undergo an autologous stem cell transplant after induction therapy.

Consolidation Therapy

Consolidation therapy consists of a few more rounds of chemotherapy. The goal of this treatment phase is to kill additional cancer cells left behind after induction therapy. Consolidation therapy is often a part of research studies called clinical trials but is not part of the usual standard of care for myeloma.

Maintenance Therapy

People who receive a stem cell transplant continue to take medication to keep cancer cells from coming back. This is called maintenance therapy. When people don’t undergo stem cell transplantation, the treatments following their first treatment phase are called continuous therapy. Immunomodulatory drugs are usually used for maintenance or continuous therapy.

Drugs Used To Treat Multiple Myeloma

The exact drugs you take to treat myeloma depend on several factors. These may include your age, your overall health, how well your kidneys are working, how fast your myeloma cells are growing, gene changes found in your cancer cells, and your personal preferences.

Technically, all drugs that kill cancer cells can be called chemotherapy. However, doctors usually use the term “chemotherapy” to refer to traditional cell-killing drugs. These chemotherapy drugs are toxic to both cancer cells and to the body’s normal, healthy cells. Other anti-cancer drug therapy works differently. Targeted therapy drugs prevent cancer cells from dividing and making copies of themselves while leaving normal cells alone. Immunomodulatory drugs boost the body’s immune system to better fight off cancer.

Chemotherapy Drugs

Traditional chemotherapy is given in cycles in which a person takes medication and then has a rest period. People with myeloma often have four to six cycles of chemotherapy, which lasts about four to six months. Some drugs may be taken daily, while others are taken weekly. Medications for multiple myeloma are taken orally (by mouth), injected under the skin, or given through an IV tube that goes directly into the vein.

Doctors most often give traditional chemotherapy drugs to people who are undergoing a stem cell transplant. Other people who are not planning on getting a transplant may not ever use traditional chemotherapies. There are several classes of chemotherapy drugs.

Alkylating Agents

Alkylating agents are a type of chemotherapy that damages a cell’s DNA, which prevents the cell from growing and eventually kills it. Alkylating agents approved to treat multiple myeloma include:

• Melphalan (Alkeran)
• Carmustine (BiCNU)
• Cyclophosphamide (Cytoxan)
• Vincristine (formerly sold as Oncovin)
• Melphalan flufenamide (Pepaxto)
• Bendamustine (Treanda)

Anthracyclines

Chemotherapy drugs called anthracyclines also damage DNA and prevent cells from dividing. Doctors may recommend doxorubicin (Adriamycin) or liposomal doxorubicin (Doxil) to treat myeloma.

Steroids

Doctors often give steroid drugs, also called corticosteroids, along with chemotherapy. dexamethasone (Decadron) and prednisone (Deltasone) are steroids used to treat myeloma. Steroids can:

• Kill myeloma cells
• Reduce inflammation and pain
• Relieve chemotherapy side effects

Immunomodulatory Drugs

Researchers aren’t sure exactly how immunomodulatory drugs fight myeloma. These drugs most likely boost the immune system, helping it better attack cancer cells. Immunomodulatory drugs used to treat myeloma include thalidomide (Thalomid), lenalidomide (Revlimid), and pomalidomide (Pomalyst).

Targeted Therapy Drugs

Targeted therapies recognize certain genes or proteins found in cancer cells. These drugs block cancer cells from growing or tell cancer cells to destroy themselves.

Proteasome Inhibitors

Proteasomes are enzymes that break down old or unneeded proteins within cells. Proteasome inhibitors block these enzymes. Proteasome inhibitors can effectively kill myeloma cells, which make large numbers of proteins. When myeloma cells can’t get rid of their extra proteins, they die.

Bortezomib (Velcade) is a proteasome inhibitor approved by the U.S. Food and Drug Administration (FDA) to treat people who are newly diagnosed with myeloma. It is often given as part of induction therapy. Other proteasome inhibitors — carfilzomib (Kyprolis) and ixazomib (Ninlaro) — are FDA approved to treat recurrent myeloma (cancer that has come back after being treated with other medications).

Histone Deacetylase Inhibitors

Panobinostat (Farydak) is a drug that recognizes proteins called histone deacetylases (HDACs). Many cancer cells, including myeloma cells, make too many HDACs, which turn off genes that keep cells running normally. HDAC inhibitor drugs block HDACs and turn on genes that slow down or stop cancer cells.

Nuclear Export Inhibitors

A cell’s nucleus contains most of the cell’s DNA. Cells need to transport proteins in and out of the nucleus to function properly. Nuclear export inhibitors are medications that prevent a cell from carrying proteins out of its nucleus. When a cell can no longer perform this task, it dies. Selinexor (Xpovio) is a nuclear export inhibitor approved by the FDA to treat myeloma.

Monoclonal Antibodies

Each monoclonal antibody recognizes one specific protein found on cancer cells. Monoclonal antibodies signal to the immune system to destroy cancer cells. They may also directly kill cancer cells themselves.

Some monoclonal antibodies recognize a protein called CD38, found on the outer surface of myeloma cells. These include daratumumab (Darzalex), daratumumab and hyaluronidase-fihj (Darzalex Faspro), and isatuximab-irfc (Sarclisa). Another monoclonal antibody, elotuzumab (Empliciti), attaches to a myeloma cell protein called SLAMF7.

The myeloma drug belantamab mafodotin-blmf (Blenrep) works differently. This medication consists of a monoclonal antibody that recognizes a protein called B-cell maturation antigen (or BCMA). The antibody is attached to a chemotherapy drug. Belantamab mafodotin-blmf brings the chemotherapy directly to cancer cells while leaving normal cells alone.

Drug Combinations To Treat Multiple Myeloma

Different types of myeloma drugs are often given together in various combinations. One of the most common treatment options is the proteasome inhibitor bortezomib, the immunomodulatory drug lenalidomide, and low doses of the steroid dexamethasone. There are many other possible drug combinations as well. These may include:

• Bortezomib, cyclophosphamide, and dexamethasone
• Lenalidomide and dexamethasone
• VAD — Vincristine, doxorubicin, and dexamethasone
• DCEP — Dexamethasone, cyclophosphamide, etoposide, and cisplatin (Platinol)

Chemotherapy Before Stem Cell Transplantation

Aggressive cancer treatment plans kill cancer more effectively, but they can also destroy healthy blood cells and stem cells (cells that produce new blood cells). Delivering new stem cells after high-dose chemotherapy can help the body rebuild its blood cells. The treatment melphalan is typically used before a stem cell transplant.

Chemotherapy Side Effects

Chemotherapy can cause many additional health problems. Common side effects include:

• Tiredness
• Hair loss
• Nausea or vomiting
• Diarrhea or constipation
• Loss of appetite
• Mouth sores
• Problems swallowing
• Pain or tingling in the hands or feet
• Trouble focusing
• Anemia (low levels of red blood cells), which may cause fatigue, dizziness, shortness of breath, and pale skin
• Low platelet counts, leading to bleeding problems
• Low levels of white blood cells, which can cause infection
• Heart, lung, or kidney problems
• Increased risk of developing other cancers

Steroid drugs also cause side effects. They may lead to:

• Sleeping problems
• High blood sugar levels
• Weight gain
• Mood changes

Steroids can also weaken the bones.

Immunomodulatory drugs can cause birth defects, so these medications shouldn’t be used by people who are pregnant, may soon become pregnant, or may soon get someone else pregnant. Immunomodulatory drugs can also cause blood clots. Taking aspirin or a blood thinner may help reduce risk. Lenalidomide and pomalidomide cause fewer side effects than thalidomide, but they can still cause bleeding problems, infections, anemia, and nerve damage.

Targeted therapies can have many different side effects, although they usually cause milder problems than traditional chemotherapy drugs. Targeted therapy drugs may lead to:

• Nausea and vomiting
• Diarrhea
• Constipation
• Tiredness
• Bleeding
• Swelling
• Breathing problems
• Rashes
• Infection

Tell your doctor about any health changes you are experiencing. Your health care team can help you learn how to manage side effects. They can recommend or prescribe other treatments that can relieve side effects and improve your quality of life.

Talk With Others Who Understand

MyMyelomaTeam is the social network for people with multiple myeloma and their loved ones. On MyMyelomaTeam, more than 16,000 members come together to ask questions, give advice, and share their stories with others who understand life with multiple myeloma.

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