Treatment to control myeloma 2

Treatment to control myeloma

* Chemotherapy
* Side effects of chemotherapy
* Stem cell transplants
* Side effects with stem cell treatment
* Thalidomide
* Side effects of thalidomide
* Steroid therapy
* Bisphosphonates

Chemotherapy

Chemotherapy is the use of anti-cancer (cytotoxic) drugs and is one of the main treatments used to control myeloma. Chemotherapy drugs circulate in the blood, and can reach myeloma cells all over the body.

One or more chemotherapy drugs are given for a few days every 3–4 weeks, followed by a rest period during which you will have regular blood tests to check the effect of the drugs. The dose of the drugs may be altered according to the results of your blood tests.

Chemotherapy may be given to you as an outpatient, but sometimes it may mean having to spend a few days in hospital.

Some drugs for myeloma are given as tablets or capsules (orally), others by injection into a vein (intravenously). The drugs melphalan and cyclophosphamide are commonly used to treat myeloma and are usually given as tablets or capsules, but can also be given into a vein. They are most often given with steroid tablets (prednisolone). When given as tablets, these drugs have fewer side effects. This makes them more suitable for people who are not able to have stronger treatments.

Some people may be offered a combination of chemotherapy drugs given by injection or infusion (drip) into a vein over a few days, again often with steroids. Two commonly used chemotherapy regimes are VAD and C-VAMP.

* VAD involves the drugs vincristine, doxorubicin and the steroid dexamethasone
* C-VAMP is a combination of the drugs cyclophosphamide, vincristine, doxorubicin and the steroid methylprednisolone

These treatments tend to have more side effects than tablets or capsules, and will often make your hair fall out. In view of this, they are usually given only to younger people who are fit enough.

A newer combination treatment for myeloma which is given as tablets is CTD. This is a combination of the chemotherapy drug cyclophosphamide, the drug thalidomide and the steroid, dexamethasone. This treatment may form part of a research trial.

If you are going to have your treatment by drip, your doctor may suggest that you have a plastic tube (such as a central line or PICC line) put into a vein in your chest or the crook of your arm.

A central line
A central line

The PICC line is threaded through a vein until the end is near to your heart
The PICC line is threaded through a vein until the end is near to your heart

The line can stay in place throughout your treatment. Your nurses will show you how to care for the line when you are at home. A tube with an injectable port just under the skin may sometimes be used. This is known as an implantable port.

The length of treatment will depend on the stage of the myeloma and how well it is responding to the drugs, but usually the course of treatment will take four–six months to complete. On average, two out of three patients will go into remission during treatment.

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Side effects of chemotherapy

Everyone reacts to chemotherapy in different ways. Not all drugs cause the same side effects and some people may have very few side effects. Your doctor will tell you about any problems that your treatment may cause.

Chemotherapy tablets for myeloma may cause fewer side effects than chemotherapy by injection or infusion into a vein.

We have further information about individual drugs and their side effects. We also have detailed information about all of the side effects mentioned in this section.
Lowered resistance to infection

Chemotherapy can reduce the production of white blood cells by the bone marrow, making you more prone to infection. This effect can begin about seven days after treatment has been given and your resistance to infection usually reaches its lowest point 10–14 days after chemotherapy. Your blood cells will then increase steadily and will usually have returned to normal before your next course of chemotherapy is due.

Contact your doctor or the hospital straightaway if:

* your temperature goes above 38ºC (100.5ºF)
* you suddenly feel unwell (even with a normal temperature).

You will have a blood test before having more chemotherapy, to make sure that your cells have recovered. Occasionally it may be necessary to delay treatment if your blood count is still low.
Bruising or bleeding

The chemotherapy can also reduce the production of platelets, which help the blood to clot. Let your doctor know if you have any unexplained bruising or bleeding, such as nosebleeds, blood spots or rashes on the skin, or bleeding gums.
Feeling sick

Chemotherapy tablets usually cause very mild feelings of sickness (nausea). With some of the injected drugs this may be more of a problem, and these may even cause vomiting. There are now very effective anti-sickness drugs to prevent or greatly reduce these effects. If nausea occurs, it may begin a few hours after the treatment is given and last for up to a day. If it is not controlled, or continues, tell your doctor. They can prescribe other drugs which may be more effective.
Sore mouth

Chemotherapy drugs can make your mouth sore, so regular mouthwashes are important; the nurse will show you how to do these properly. If you don't feel like eating at any time during your treatment, you could replace some meals with nutritious drinks or a soft diet. It might be helpful to speak to the hospital dietitian.
Anaemia (low number of red blood cells)

While having chemotherapy you may become anaemic. This may make you feel tired and breathless.
Hair loss

Hair loss is more common with chemotherapy given into a vein than it is with chemotherapy tablets. If your hair falls out, it usually grows back within three months after treatment.
Tiredness (fatigue)

Chemotherapy affects people in different ways. Some are able to lead a fairly normal life during their treatment, while others find they become very tired and have to take things more slowly. Just do as much as you feel like and try not to overdo it. For some people, the fatigue continues for quite some time after their treatment has ended.

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Stem cell transplants

If they go into remission after the initial chemotherapy, some people can go on to have high-dose chemotherapy to try to destroy any remaining myeloma cells.

The high doses of chemotherapy will destroy the bone marrow as well as the myeloma, so the bone marrow will need to be replaced with a transplant of stem cells. The stem cells are collected before the treatment, stored and then given by drip into a vein afterwards. This is known as an autologous transplant.

As this is a very intensive treatment with a lot of side effects, it is usually only suitable for people under 65–70, although your general health rather than your age is the main deciding factor.

It may also be possible to have a stem cell transplant as part of a research trial, using donated stem cells, either from your brother or sister, or from an unknown donor. When the stem cells are donated by a brother or sister, this is called an allogeneic transplant. The risks of this treatment are greater than if you use your own stem cells and, as a result, it is usually only available to people under 50.

A matched unrelated donor (MUD) transplant, where the donor is not related to the patient, has more side effects than one using cells from a relative. MUD transplants are rarely used to treat people with myeloma.

Our section stem cell and bone marrow transplants explains this treatment in more detail.

Other treatments involving the use of stem cells are being researched in some hospitals. These include mini-transplants (which involve less intense chemotherapy), and tandem transplants (in which a second transplant is given straight after the first). It is not yet known how effective these methods will be.

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Side effects with stem cell treatment

If high doses of chemotherapy with stem cell (or bone marrow) support are used, the side effects of the chemotherapy can be more severe and you will need to stay in hospital for about four weeks. This is because the treatment will make the number of blood cells and platelets in your blood drop to very low levels for a few weeks. During this time, people often need to be given antibiotics to prevent infections, as well as blood transfusions and transfusions of platelets to prevent any bleeding.


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Thalidomide

Thalidomide is a drug that has been shown to be effective in treating myeloma. It may be given to treat myeloma that has relapsed (come back). Research trials are also looking into its use as a maintenance treatment for myeloma, especially after high dose treatment, and also its use as an initial treatment given with chemotherapy.

It is thought that thalidomide can stop cancers from developing new blood vessels, and may be able to stop the cancer getting a supply of oxygen and nutrients. It is hoped that this will stop the cancer growing or make it shrink.

Thalidomide is taken daily, usually in the evening, as a tablet.

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Side effects of thalidomide

These include constipation; drowsiness; an increased risk of developing blood clots in the veins in the legs (known as deep vein thrombosis or DVT); and damage to particular nerves, which can cause tingling in the hands and feet (peripheral neuropathy). You may be given medicines to thin your blood because of the risk of blood clots.

Peripheral neuropathy is a common side effect of thalidomide. It usually starts with tingling and numbness in the feet which then spreads to the hands. It's important to tell your doctor if you have any symptoms so they can adjust the dose if appropriate. The degree of neuropathy may depend on the dose and how long you take thalidomide for. People who have had chemotherapy which causes peripheral neuropathy may be more at risk.

Thalidomide can cause birth defects, so its use is strictly controlled. It should not be given to pregnant women, and people taking thalidomide who are sexually active should use a barrier form of contraception.

Occasionally the side effects outweigh any benefit, and the dose of thalidomide will be reduced or stopped.

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Steroid therapy

Steroids are drugs which are often used in the treatment of myeloma. They may be taken on their own or with chemotherapy. The steroids are usually taken as tablets.

Steroids for myeloma are usually taken only for a few days at a time. Depending on the dose prescribed, they may have some side effects. These can include feeling irritable, increased appetite, feeling more energetic, heartburn, indigestion and difficulty sleeping.

If you are taking steroids for some time, you may have other temporary side effects including water-retention, high blood pressure and a slightly greater risk of getting infections. You may also develop an increased level of sugar in the blood. If this happens to you, your doctor will prescribe daily tablets or injections to bring your blood sugar level back to normal.

You may need to do a simple daily test to check for sugar in your urine. Your nurses will show you how to do this.

It is unusual for people with myeloma to have to take steroids for a long time but if you do you, may notice that you put on weight, especially on your face, waist and shoulders.

These side effects may seem hard to bear at the time, but it is important to remember that they are all temporary and will disappear as the steroid dose is reduced.

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Bisphosphonates

Bisphosphonate drugs can be given to reduce the symptoms of myeloma. They may be used to reduce the amount of excess calcium in the blood and to help strengthen weakened bones. They are also be given to people in remission, as they have been shown to help delay bone damage, and to prevent bone pain, raised calcium levels and fractures.

Research has suggested that bisphosphonates may help treat myeloma. Trials are investigating this further.

Bisphosphonates can be given in two ways. They can be given as a drip (infusion) into a vein once a month. This takes between 15 minutes and four hours, depending upon which drug is used. Bisphosphonates are also available as tablets.

Side effects are generally mild and include indigestion and nausea. A very rare side effect of bisphosphonates is osteonecrosis of the jaw. This condition involves damage and decay of the jaw bone. It is more likely if a person has had dental treatment just before or during treatment with bisphosphonates. It is important that your dentist knows if you are on bisphosphonates and that your doctors know if you need dental treatment.