Chemotherapy for Myeloma

Overview
Chemotherapy is the treatment of cancer with drugs that destroy or slow the growth of cancer cells. Some doctors may refer to all medication prescribed for someone with myeloma as chemotherapy. High-dose chemotherapy followed by autologous stem cell transplant is the most common treatment for people when first diagnosed with multiple myeloma. Certain chemotherapy drugs must be infused intravenously (by IV), while others are injected or taken orally. Chemotherapy is usually prescribed by a medical oncologist – a doctor who specializes in treating cancer with medications.

There are many classes of chemotherapy drugs for myeloma. Most chemotherapy drugs used for myeloma are given in combinations of two or more drugs depending on the type of myeloma you have, the stage of your myeloma, whether you have tried other therapies before, and whether or not you are going to receive a stem cell transplant. If your myeloma progresses, or if you experience significant side effects, your medical oncologist may adjust your dosage or change the combination of drugs you receive.

Classes of chemotherapy drugs used for myeloma include alkylating agents, anthracyclines, and proteasome inhibitors. Alkylating agents such as Alkeran (Melphalan), Cytoxan (Cyclophosphamide), and Treanda (Bendamustine) are believed to prevent the growth of cancer cells by inhibiting and damaging their DNA. Anthracyclines including Adriamycin (Doxorubicin) and Doxil (Liposomal doxorubicin) slow the growth of cancer cells by interfering with cell division. Normal cells have the ability to self-destruct if they become cancerous. In cancer cells, this function is turned off, allowing abnormal cells to keep growing and replicating. Proteasome inhibitors such as Kyprolis (Carfilzomib), Ninlaro (Ixazomib), and Velcade (Bortezomib) are believed to work by activating this self-destruct function in cancer cells.

Chemotherapy medications may be combined with other classes of drugs including corticosteroids such as Dexamethasone and Prednisolone or immunomodulators like Thalomid (Thalidomide), Revlimid (Lenalidomide), and Pomalyst (Pomalidomide). These drugs may enhance the effects of chemotherapy or reduce side effects. Biologics such as Darzalex (Daratumumab) and Empliciti (Elotuzumab) are genetically engineered proteins that can kill cancer cells directly or aid the immune system in targeting and destroying cancer cells.

Most people with myeloma receive a chemotherapy regimen that involves two or more medications from different drug classes. Drug combinations used for chemotherapy to fight myeloma include:

• CTD (Cytoxan, Thalomid, and Dexamethasone)
• KRD (Kyprolis, Revlimid, and Dexamethasone)
• MPT (Melphalan, Prednisolone, and Thalomid)
• MPV (Melphalan, Prednisolone, and Velcade)
• RD (Revlimid and Dexamethasone)
• VD (Velcade and Dexamethasone)
• VRD (Velcade, Revlimid, and Dexamethasone)
• VCD or CyBorD (Velcade, Cytoxan, and Dexamethasone)
• VTD (Velcade, Thalomid, and Dexamethasone)

What does it involve?
A course of chemotherapy is administered in cycles of treatment and recovery. Most people with myeloma will receive between four and 12 cycles of chemotherapy in one complete course. A course of chemotherapy usually lasts approximately four to six months. During treatment, chemotherapy is administered for several days. Each period of treatment will be followed by a recovery period of a few weeks to allow your body to rest. Your medical oncologist will determine your chemotherapy schedule based on many factors, including the type and stage of your myeloma, how well your cancer responds to treatment, and the severity of the side effects you experience.

If myeloma progresses after the first course of chemotherapy with one drug combination, your medical oncologist may recommend trying another course with a different combination. If an initial round of chemotherapy successfully delays progression for a time, but your myeloma later relapses, your doctor may suggest undergoing another course of chemotherapy with the same or a different drug combination.

Before you begin chemotherapy, it is a good idea to work on improving your overall health. Get plenty of rest and avoid stress. Eat a healthy diet focused on whole grains, fresh vegetables, and fruit. Visit your dentist for a check-up and cleaning. Ask your doctor whether you need flu or pneumonia vaccinations or other immunizations. These steps can help you cope with side effects and avoid infections during chemotherapy treatment.

Before chemotherapy treatment begins, your medical oncologist will review the results of all of your tests and scans and recommend chemotherapy regimens that may work for you. They will go over the benefits and side effects associated with each option. Once a regimen has been chosen, the oncologist will walk you through the treatment consent form and get your signature.

If you are taking chemotherapy drugs orally, you can do it at home. If you are taking chemotherapy drugs intravenously, you will usually need to receive them in a clinical setting such as a doctor’s office or cancer treatment center. You may receive them through a slow-drip IV infusion in your hand or arm, as an intramuscular (into the muscle) or subcutaneous (under the skin) injection, or you may have a line or a port implanted.

A line or port is a flexible plastic tube inserted just under the skin in your arm or chest. If you receive a port or a line for chemotherapy, it will be placed during a brief outpatient surgery. The benefit of having a device implanted for chemotherapy is that you can receive medication or have blood taken through them without having the discomfort of a needle stick each time. If you do have a line or a port, monitor the skin around the device carefully for any sign of infection. After your chemotherapy treatments are finished, the device will be quickly and easily removed.

Each chemotherapy treatment can last one or several hours. To help pass the time, you can bring books, an electronic tablet or a laptop, knitting, materials for writing letters, puzzles, a board game and a friend, or anything else that you might enjoy. You can also take a nap.

After a chemotherapy session, the nurse or chemotherapy technician may check your vitals again to make sure you are stable after receiving the drugs. You may feel able to drive yourself home, but it might be easier to arrange a ride in advance. You may feel very fatigued and need to rest for a day or two after receiving chemotherapy. Be sure to drink plenty of fluids in order to avoid dehydration and constipation. Avoid beverages containing alcohol and caffeine, since they can worsen dehydration.

While you are undergoing chemotherapy treatment, your doctor will order tests regularly to check the effectiveness of the drug regimen and the severity of any side effects. These tests may include magnetic resonance imaging (MRI) scans, computerized tomography (CT or CAT) scans, or positron emission tomography (PET) scans to check for new bone lesions. The doctor may order bone marrow biopsies and flow cytometry (laboratory testing) to examine the bone marrow for cancer cells, and blood and urine tests to check blood cell counts, levels of myeloma proteins, and kidney function. Your doctor may change your chemotherapy regimen based on the results of these tests.

Intended outcomes
In people with myeloma, chemotherapy can help slow or stop the growth of cancer cells. In some cases, chemotherapy can result in complete remission from myeloma.

Results
The effectiveness of chemotherapy in cases of myeloma varies widely by type and stage of myeloma, which chemotherapy regimen is used, and whether it is combined with other drugs. The recent introduction of several new medications has improved overall results for myeloma treatment, but the novelty of the drugs means that there is limited comparative data on long-term results such as relapse rate and survival rate.

Constraints
Most chemotherapy drugs work against cells that divide and multiply very quickly. This makes them effective against cancer cells. However, healthy cells in certain parts of your body – bone marrow, hair, and the lining of the digestive system – also divide rapidly. Therefore, many common side effects of chemotherapy are related to damage in these areas.

Each class of chemotherapy drugs causes different side effects, some of which are very serious. What side effects you experience will depend on many factors including which drug combination your doctor prescribes, your dosage, and how well your body can tolerate the treatment. If you cannot tolerate the side effects, your doctor will try decreasing dosage or changing the combination in an effort to minimize danger and discomfort. Always report side effects to your doctor. Some side effects, such as nausea, can be eased with other medications.

Some of the most common side effects of chemotherapy include fatigue, nausea, vomiting, diarrhea, loss of appetite, weight loss, neuropathy (nerve pain, tingling, or numbness), hair loss, and mouth sores. Damage to bone marrow often results in a weakened immune system due to low white blood cell counts. You may bruise or bleed easily due to low levels of platelets, a blood component that causes clotting. Anemia (low red blood cell count) contributes to fatigue, dizziness, and shortness of breath. Other side effects of chemotherapy can include severe exhaustion, trouble swallowing, joint pain and skin changes such as nail discoloration and thin, brittle hair. Chemotherapy may also cause skin problems such as bruising or bleeding at the injection site, chest pain, fever and chills, or allergic reactions. Some people report cognitive side effects from chemotherapy such as memory problems and trouble focusing or planning. These cognitive issues are sometimes referred to as “chemo brain.” These side effects usually disappear soon after the end of treatment, although fatigue may last for years after treatment is over.

Chemotherapy treatment also affects male and female reproduction in many ways, both temporary and permanent. People who will be taking drugs that can cause infertility may choose to store sperm or fertilized eggs so that they can try for pregnancy at a later time. It is possible to become pregnant while receiving chemotherapy, but chemotherapy drugs taken by the father or mother can cause harm to a developing fetus. Talk to your doctor about safe and effective birth control methods to use while on chemotherapy. Chemotherapy medications can stay in the system for some months after treatment ends, so discuss safe timing with your doctor before trying to conceive.

Some chemotherapy drugs can cause neuropathy, or nerve damage. This may result in pain, tingling, or numbness in the extremities. These symptoms may be temporary or permanent.

Some potential late side effects of chemotherapy for myeloma can arise months or even years after treatment is complete. Some chemotherapy drugs can cause cardiotoxicity, or damage to the heart. This damage can lead to arrhythmia (changes in heart rhythm) or cardiomyopathy (deterioration of the heart muscle). Other drugs can damage the lungs, bring on early menopause, or make some people susceptible to other cancers in the years following treatment.

Out-of-pocket expenses for chemotherapy treatments can be difficult for some people to afford. Others find it impossible to work during or after myeloma treatment. For these reasons, some people may find it difficult to recover financially after treatment for myeloma.

For more details about this treatment, visit:

Drug Therapy for Multiple Myeloma – American Cancer Society
https://www.cancer.org/cancer/multiple-myeloma/...

Chemotherapy and Drug Therapy – Leukemia and Lymphoma Society
http://www.lls.org/disease-information/myeloma/...

Patient education: Multiple myeloma treatment (Beyond the Basics) – UpToDate
https://www.uptodate.com/contents/multiple-myel...

Myeloma-About chemotherapy – Cancer Research UK
https://www.cancerresearchuk.org/about-cancer/m...

Chemotherapy – Macmillan Cancer Support
https://www.macmillan.org.uk/information-and-su...

Personal Financial Effects of Multiple Myeloma and its Treatment – Cancer Nursing
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC39...

Multiple Myeloma: Types of Treatment – Cancer.net
https://www.cancer.net/cancer-types/multiple-my...