Multiple myeloma is treated through a combination of approaches tailored to the patient’s age, overall health, and disease characteristics. The main goal is to reduce cancerous plasma cells, control symptoms, and prolong remission.
For younger patients, typically under 65, the preferred treatment starts with **high-dose chemotherapy**, often using drugs like bortezomib combined with lenalidomide and dexamethasone. This is usually followed by an **autologous stem cell transplant (ASCT)**, where the patient’s own stem cells are collected, the patient receives intensive chemotherapy to kill myeloma cells, and then their stem cells are infused back to restore bone marrow function. This approach is not a cure but can significantly prolong survival and deepen remission.
There is also an **allogeneic stem cell transplant**, which uses stem cells from a healthy donor. This has the potential for a cure but is rarely used initially due to higher risks, including a 5–10% treatment-related mortality rate. It is generally reserved for relapsed cases in select patients.
For older patients or those with other health problems who cannot tolerate stem cell transplants, treatment usually involves chemotherapy regimens such as melphalan and prednisone. Newer combinations including bortezomib or lenalidomide with low-dose dexamethasone have improved outcomes in this group, showing survival rates around 80-90% at two years.
**Monoclonal antibodies** have become a cornerstone of multiple myeloma treatment. These are lab-made proteins that target specific markers on myeloma cells, such as the CD38 protein. Drugs like daratumumab and isatuximab bind to CD38, helping the immune system recognize and kill myeloma cells. Another antibody, elotuzumab, targets the SLAMF7 protein. These antibodies are often combined with other therapies and can be used in initial treatment or relapse.
**CAR T-cell therapy** is an advanced immunotherapy option for patients whose disease has relapsed or become resistant to other treatments. This involves collecting a patient’s T cells, genetically modifying them in the lab to recognize a protein called BCMA on myeloma cells, and then reinfusing them to attack the cancer. Approved CAR T-cell therapies include idecabtagene vicleucel and ciltacabtagene autoleucel. This treatment is typically a one-time infusion followed by close monitoring.
Another emerging immunotherapy is **bispecific T-cell engagers (BiTEs)**, which are antibodies designed to bind both myeloma cells and T cells simultaneously, activating the immune system to kill cancer cells. These are used mainly for relapsed or refractory myeloma and target proteins like BCMA or GPRC5D on myeloma cells.
Other drugs used in multiple myeloma treatment include:
– **Proteasome inhibitors** (e.g., bortezomib, carfilzomib) that disrupt the cancer cells’ ability to break down proteins, leading to cell death.
– **Immunomodulatory drugs** (e.g., lenalidomide, pomalidomide) that enhance the immune response and have direct anti-myeloma effects.
– **Steroids** (e.g., dexamethasone) that help reduce inflammation and kill myeloma cells.
Radiation therapy can be used to relieve bone pain or treat localized areas of disease.
Treatment is often given in phases:
1. **Induction therapy** to reduce the number of myeloma cells.
2. **Stem cell transplant** for eligible patients to consolidate response.
3. **Maintenance therapy** with drugs like lenalidomide or monoclonal antibodies to prolong remission.
For patients who relapse, treatment options depend on prior therapies and may include combinations of the above drugs, newer agent
