Treatment options

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The described treatment methods are supported by data from clinical trials. It is possible to implement one of the stated treatment methods or a combination of several methods.

Radiotherapy

Radiotherapy (irradiation with ionizing radiation) is a form of treatment where cancer myeloma cells are destroyed by irradiation. This stops them from spreading and causing possible damage. Radiotherapy is mainly used for treating menacing and painful bone abnormalities, bone fractures and when there is a larger myeloma infiltration outside the bone marrow or when the growth on the bone occurs. Irradiation is mandatory in cases when myeloma infiltration puts pressure on the spinal cord and is the cause of clinical difficulties that could result in the paralysis of the limbs.

Chemotherapy

Treatment with cytotoxic drugs which destroy cancer cells and inhibit cell division is called chemotherapy. Chemotherapy is one of the most effective methods for preventing the spread of the disease in the bone marrow and outside it with patients suffering from multiple myeloma. Patients receive some chemotherapy drugs (cytotoxic) in the tablet form, others are taken intravenously. These two methods are usually used with corticosteroids, but also in combination with new drugs as this enables treatment to be more effective.

Although chemotherapy destroys cancer cells rapidly, it also affects normal and healthy cells. The effect is more prominent on the rapidly dividing cells, e.g. hematopoietic cells, cells in the lining of the gastrointestinal and respiratory systems. This can lead to unwanted side effects, e.g. bone marrow depression (anemia, heightened risk of infections and prone to bleeding), infections in the lining of respiratory and gastrointestinal systems, diarrhea, vomiting, loss of appetite.

Nausea and temporary hair loss are also some of the unwanted side effects of chemotherapy. Irrespective of the severity of the side effects, one should be aware that these are of a temporary nature and relate only to the first or second round of treatments and in most cases unavoidable if complete and effective treatment is to be expected.  By all means, do not hesitate to ask your physician about all the unwanted side effects may occur with your chemotherapy. If, during any stage of the chemotherapy you feel unease and concern, a physician or medical staff should be informed immediately. It is possible that the treatment method will lose its efficacy after some time (it is impossible to predict the time frame). Myeloma cells become unresponsive and resistant to treatment with chemotherapy or other medication.

Corticosteroids

These drugs are very similar in composition to cortisone. Cortisone is a natural hormone excreted by the adrenal glands. They are often used to treat inflammations of various causes. Prednisone and dexamethasone are the two corticosteroids most commonly used for multiple myeloma treatment. These drugs are taken separately, in most cases in combination with other drugs. Treatment with corticosteroids is accompanied by some unwanted side effects: insomnia, increased appetite, restlessness, mood swings, ulcers in the stomach lining and duodenum, opacity of the eye lens and disruptions in regulating blood glucose levels.

Transplantation of hematopoietic stem cells and high-dose chemotherapy

Within the scope of HSCT, high-dose chemotherapy destroys many more myeloma cells as compared to classical chemotherapy, therefore it reduces the burden of the disease tremendously. High-dose chemotherapy also destroys a large percentage of hematopoietic stem cells in the bone marrow which vital for life. This is why high-dose chemotherapy is followed by HSCT. This substitute destroyed hematopoietic stem cells. Before the treatment these cells must be gathered which is feasible in 90% of patients. Related to a number of new drugs, a high-dose chemotherapy often results in very positive treatment outcomes.

If the patient's hematopoietic stem cells are used for HSCT, we talk about 'autologous HSCT'. These cells are removed from the patient’s blood stream and are kept cryopreserved outside the body before the onset of chemotherapy treatments. As a rule, cells are removed and saved for more autologous HSCT. In some cases, related and un-related donors have to be summoned to donate hematopoietic stem cells. This is called allogenic HSCT.

Transplantation of your own stem cells (autologous transplantation)

This type of HSCT is most commonly used. Lower risk of complications are expected with this type in comparison to allogenic HSCT. Autologous HSCT enables the patient to receive his own previously deprived hematopoietic stem cells after receiving chemotherapy. After receiving own hematopoietic stem cells, the bone marrow still requires a two week recovery period.

During this period, patients receive antibiotics to avoid possible infections, antifungal medication and blood products transfusion. You will be hospitalized for 3 to 4 weeks, to allow your blood to get ‘back to normal’. During this period you will probably feel discomfort. Perhaps you will be put in an isolated sterile room with movement restriction required in order to minimize the risk of infection. In some cases, two successive autologous HSCT will be carried out in a period of only two months. If your condition is stable enough to allow such tandem HSCT, the results are more favorable than with a single HSCT.

Transplantation with donor's hematopoietic stem cells (allogenic transplant)

This type of transplantation uses hematopoietic stem cells from other persons. Sometimes, when this is possible, the donor is a patient’s relative. Most suitable donors are usually siblings. If there is no suitable donor within the family, stem cells have to be found elsewhere. Stem cell donors are registered in special banks in various countries. There are two key advantages to a transplantation that includes hematopoietic stem cells of a donor: cells of the donor are not contaminated with cancer plasma cells (as is the case with autologous HSCT) and also, the immune system of the donor can recognize and destroy remaining cancer plasma cells in the patient’s body (response of the graft on the tumor).

On the other hand, this method comes with its downsides as well. There is always a possibility that a life-threatening reaction to the transplantation may occur (GVHD – Graft Versus Host Disease). This is a condition where patient’s organs and tissue are attacked by the donor’s hematopoietic stem cells and lymphocytes. Any organ could be affected by this condition, but in most cases gastrointestinal organs, liver and skin are affected. The patient is required to take immunosuppressant drugs, and so the probability that an infection will occur is higher. Therefore, the mortality rate in patients with this type of transplant is higher compared to the mortality rate with autologous HSCT. There is also a possibility that the quality of life will be considerably reduced. Allogenic transplant procedure is in most cases carried out on younger patients who have adverse chromosomal disease characteristics.

Transplant of own hematopoietic stem cells followed by a transplant of the donor's cells. This method of treatment consists of transplanting own hematopoietic stem cells followed by a mini allogenic HSTC. In the beginning the patient receives a high-dose chemotherapy which significantly reduces the tumor burden of the cancer plasma cells. Autologous HSTC with the patient’s hematopoietic stem cells is subsequently carried out. If reached tumor burden is small enough, the second stage of the treatment begins. The patient receives a transplant of the donor’s hematopoietic stem cells. This enables the donor’s cells to start attacking remaining patient’s cancer plasma cells – this is called immune response to attack tumors.

Regardless of the HSCT, the side effects are more pronounced compared to a classical chemotherapy and remain more or less the same: vomiting, nausea, diarrhea, general fatigue and helplessness. In the long run, the risk of lung, heart, kidney or liver damage is expected and related to HSCT. The risk of infections of patients suffering from immune response deficiency is to be expected as well.

Supportive therapy

CEE_MM_treatment_02
Stock photo. Posed by model.

Supportive therapy is intended for patients suffering from multiple myeloma and is an integral and important part of recovery. It includes therapies that reduce symptoms and complications. Among other things this includes blood transfusions of blood products, treatment with bisphosphonates, growth factors, antibiotics, intravenous fluid and nutrient replacement, diuretics and intravenous immunoglobulins.

Bisphosphonates are drugs taken to reduce and prevent bone damage caused by multiple myeloma. This group of drugs prevents bone degradation caused by the disease. Some drugs even extend survival rates of the patients. Bisphosphonates are taken daily or monthly by all multiple myeloma patients where skeletal changes occur. Bisphosphonate treatment is restricted to a period between 12 and 24 months due to unwanted side effects.

Your treating physician should monitor renal function during the treatment. Because of bisphosphonate use, part of the bone can die, especially in the region of the jaw (osteonecrosis of the jaw). This is common with patients who have unresolved dental problems. This is the reason to pay a visit to the dentist’s prior to starting the treatment. With regard to dental effects, please consult the hematologist.

Sometimes an orthopedic procedure is needed to alleviate pain or provide secure flexibility of the spine. In case of a vertebra fracture a procedure called vertebroplasty or kyphoplasty will be carried out. Vertebroplasty is a procedure where a needle is used to inject bone cement into a vertebra, this stabilizes the bone damage. Kyphoplasty is a procedure where a special balloon is inserted and then inflated. This enables the intervertebral disc to be put back into the correct position, followed by injecting cement in the vacant space.

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