Multiple Myeloma: Chemotherapy and Targeted Therapy

What are chemotherapy and targeted therapy? 

Chemotherapy (chemo) is the use of medicines to kill cancer cells. The medicines attack and kill cancer cells, which grow quickly. Some normal cells also grow quickly. Because of this, chemo can also harm those cells. This can cause side effects.

Targeted therapy medicines work differently from standard chemo medicines. They target specific parts of cancer cells, like genes and proteins. They tend to cause different side effects than chemo.

When are these medicines used for multiple myeloma? 

Chemo and targeted therapy are the main treatments for people with multiple myeloma. These medicines are often used along with immunotherapy medicines. The type of medicines you get will depend mainly on:

  • How quickly the myeloma is likely to grow and cause problems

  • Whether or not you might be able to have a stem cell transplant

  • The goal of treatment

  • Your age and overall health

  • Concerns you have about side effects

  • What treatments you’ve had in the past

  • Your preferences

Your healthcare provider may recommend using 1 or more of these medicines to treat myeloma in these situations:

  • As the first treatment for myeloma

  • As part of a stem cell transplant

  • As a later treatment if the first treatment is no longer working or if the myeloma starts growing again after treatment

  • As maintenance therapy after initial treatment to help keep myeloma in remission

How are these medicines given for multiple myeloma?

Before treatment starts, you’ll meet with a medical oncologist. This is a doctor who specializes in treating cancer with medicines. These include chemo and targeted therapy. The doctor will talk with you about your treatment options and explain what you can expect. 

The medicines used to treat multiple myeloma are given in 1 of these ways: 

  • Intravenous (IV). You’ll get the medicine through a small catheter that’s been put into a vein in your hand or arm. The medicine may drip in slowly over a few hours, or you may get it over a few minutes. 

  • Subcutaneous (subQ). You’ll get this medicine as an injection (shot) under your skin.

  • Oral. You swallow these medicines as pills or liquids.

Chemo and targeted therapy medicines are normally given in an outpatient setting. This means you get them at a hospital, clinic, or healthcare provider's office. Then you go home after treatment. Less often, you may need to stay in the hospital during treatment.

Your treatment team will watch you for reactions during your treatments. Since each of your treatments may last for a while, you may want to take something that’s comforting to you, like music to listen to. You may also want to bring something to keep you busy, such as a book or mobile device.

To reduce the damage to healthy cells and to give them a chance to recover, you’ll get these medicines in cycles. Each cycle consists of 1 or more days of treatment, followed by some time to rest. In general, cycles last 3 or 4 weeks. Your healthcare provider will discuss your treatment schedule with you.

Which medicines are used to treat multiple myeloma?

Standard chemo medicines

Chemo is most often used as part of a stem cell transplant. But it can be useful in other situations, too. These are some common chemo medicines used to treat myeloma:

  • Bendamustine

  • Cyclophosphamide

  • Cisplatin

  • Doxorubicin

  • Etoposide

  • Melphalan

  • Vincristine

Immunomodulating medicines

The way immunomodulating medicines affect the immune system isn’t fully understood. There are 3 of these medicines used to treat multiple myeloma:

  • Thalidomide

  • Lenalidomide

  • Pomalidomide

The first of these medicines to be developed was thalidomide. It causes severe birth defects when taken during pregnancy. Because the other immunomodulating medicines are related to thalidomide, it’s possible they could also cause birth defects. Because of this, you can only get these medicines through a special program run by the medicine company that makes them.

Targeted therapy medicines

There are many kinds of targeted therapy medicines used to treat multiple myeloma. They include:

  • Proteasome inhibitors. These include bortezomib, carfilzomib, and ixazomib. These medicines target enzymes in cells, called proteasomes, to help control cell division.

  • Histone deacetylase (HDAC) inhibitors. Panobinostat is a medicine that affects histones. These are proteins that affect which genes a cell uses.

  • Monoclonal antibodies. These include daratumumab and elotuzumab. These medicines target proteins on the cell surface of myeloma cells. By doing this, they can kill cancer cells and/or help the immune system find and attack them.

Other medicines

Corticosteroids such as dexamethasone or prednisone are often an important part of the treatment for multiple myeloma. They're often given along with other medicines.

Combining different types of medicines

In most cases, more than 1 medicine is used to treat multiple myeloma. Many different combinations can be used. For instance, some common combos used as the first treatment for myeloma include:

  • Bortezomib, lenalidomide, and dexamethasone

  • Bortezomib, cyclophosphamide, and dexamethasone

  • Lenalidomide and dexamethasone

  • Daratumumab, bortezomib, melphalan, and prednisone

What are common side effects of these medicines?

Side effects of chemotherapy medicines

Side effects of chemo medicines are different for everyone. They vary based on the medicines you get. Below is a list of the some of the most common side effects of chemo. Ask your healthcare provider for details about the side effects for the chemo medicines you're getting.

Hair loss

If you have hair loss, the hair will often grow back after the treatment stops.

Nausea and vomiting

This side effect can be controlled and even prevented with medicines.

Mouth sores

Chemo can sometimes cause mouth sores. This might make it hard for you to eat or swallow. It's important to keep your mouth very clean and avoid foods and substances that could irritate your mouth.

Loss of appetite or changes in the way things taste

Talk to your healthcare provider if you find you’re having trouble eating or are losing weight. There are often ways to help.

Increased risk for infection

During chemo treatment, your white blood cell count may drop. This means your immune system won’t be working as well as it should. During this time, try to avoid people who have illnesses that you could catch. It’s also a good idea to take extra safety measures against cuts and scrapes that could become infected. Your healthcare provider will check your blood counts regularly during treatment. Let your healthcare provider know if you have any signs of an infection. Symptoms include fever, sore throat, a new cough, or burning during urination.

Bleeding and bruising more easily

Chemo can also lower your blood platelet counts. Platelets are needed to help the blood clot. You may bruise or bleed more easily when your platelet counts are low.

Fatigue

You may feel very tired while getting chemo. This normally goes away over time once treatment ends.

Side effects of other medicines

Proteasome inhibitor side effects can include:

  • Nausea and vomiting

  • Tiredness

  • Diarrhea or constipation

  • Fever

  • Loss of appetite

  • Low blood cell counts, especially low platelet counts. This can increase your risk of bleeding and bruising.

  • Nerve damage (peripheral neuropathy) that can lead to numbness, tingling, or pain in your hands and feet.

HDAC inhibitor side effects can include:

  • Severe diarrhea

  • Tiredness or weakness

  • Nausea and vomiting

  • Loss of appetite

  • Fever

  • Swelling in your arms or legs

Corticosteroid side effects can include:

  • Increased appetite

  • Weight gain

  • High blood sugar levels

  • Trouble sleeping

  • Feeling like you have too much energy

Working with your healthcare provider

It's important to know which medicines you're taking. Write their names down, and ask your healthcare team how each medicine works and what side effects each might have.

Talk with your healthcare providers about what signs to look for and when to call them. For example, chemotherapy can make you more likely to get infections, which can cause fever and chills. Make sure you know what number to call with questions. Is there a different number for evenings and weekends?

It may be helpful to keep a diary of your side effects. A written list will make it easier for you to remember your questions when you go to your appointments. It will also make it easier for you to work with your healthcare team to make a plan to manage your side effects.

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