Treatments for transplant eligible multiple myeloma

People with active multiple myeloma have symptoms related to the disease. Your healthcare team will first decide if you can have a stem cell transplant. If you can have a stem cell transplant, this is called transplant eligible multiple myeloma. If you can't have a stem cell transplant, this is called transplant ineligible multiple myeloma. Find out more about treatments for transplant ineligible multiple myeloma.

You are considered transplant eligible if you meet the criteria set by your treatment centre, but it usually means you are 70 years of age or younger and are in generally good health.

The goals of treatment for transplant eligible multiple myeloma are to achieve the best possible response to treatment and to maintain the response as long as possible. Your own goals for treatment are also important.

There are 3 main phases of treatment for transplant eligible multiple myeloma.

Induction therapy is the first phase of treatment for multiple myeloma. The goal of induction therapy for multiple myeloma is to lower the number of abnormal plasma cells (called myeloma cells) in the bone marrow and the number of M-proteins made by the myeloma cells. Induction therapy often includes targeted therapy and other drugs such as chemotherapy or corticosteroids or both.

Consolidation therapy is sometimes given after a stem cell transplant. It's a short course of combination therapy with targeted therapy and chemotherapy, which can help improve the outcome of a stem cell transplant.

Maintenance therapy is given after other treatments to help multiple myeloma stay in remission. Maintenance therapy is used after a stem cell transplant. The drugs used in maintenance therapy are usually targeted therapy drugs.

The following are treatment options for transplant eligible multiple myeloma. Your healthcare team will suggest treatments based on your needs and work with you to develop a treatment plan.

Induction therapy is the first phase of treatment for multiple myeloma. The goal of induction therapy for multiple myeloma is to lower the number of myeloma cells in the bone marrow and the number of M-proteins made by the myeloma cells. Induction therapy often includes targeted therapy and other drugs such as chemotherapy or corticosteroids or both.

Induction therapy is usually given for 3 to 4 cycles before proceeding to a stem cell transplant.

The following drug combinations may be used for induction therapy for transplant eligible multiple myeloma:

• RVD – lenalidomide (Revlimid), bortezomib (Velcade) and dexamethasone
• D-RVD – daratumumab (Darzalex), lenalidomide, bortezomib and dexamethasone
• CyBorD – cyclophosphamide, bortezomib and dexamethasone
• Dara-CyBorD – daratumumab, cyclophosphamide, bortezomib and dexamethasone
• VTd-PACE – bortezomib, thalidomide, low-dose dexamethasone, cisplatin, doxorubicin, cyclophosphamide and etoposide

These drugs may not be covered by all provincial and territorial health plans.

Find out more about targeted therapy for multiple myeloma and chemotherapy for multiple myeloma.

After induction therapy, you will have a stem cell transplant. The most common type of stem cell transplant for multiple myeloma is an autologous stem cell transplant. An autologous stem cell transplant is when stem cells are collected from your own blood or bone marrow rather than from a donor.

You will be given a combination of cyclophosphamide and granulocyte colony-stimulating factor (G-CSF) to stimulate the stem cells to grow faster and move into the blood from the bone marrow. Your stem cells with then be collected and stored.

Once your stem cells have been collected, you will have high-dose chemotherapy with the drug melphalan. This treatment is called conditioning. Conditioning helps destroy the cells in the bone marrow.

Find out more about stem cell transplant for multiple myeloma.

Consolidation therapy for multiple myeloma is sometimes given after a stem cell transplant. It’s a short course of treatment (2 to 4 cycles) to keep the cancer in remission for a longer time.

Consolidation therapy for transplant eligible multiple myeloma is most often the RVD regimen. The RVD regimen uses lenalidomide (Revlimid), bortezomib (Velcade) and dexamethasone. The drug daratumumab (Darzalex) can also be added to the RVD regimen.

Find out more about targeted therapy for multiple myeloma.

Maintenance therapy is given after a stem cell transplant. A maintenance therapy drug is usually given in a low dose over a long period of time. This helps to keep multiple myeloma in remission and prevent a relapse. Because the drug is given at a low dose, there tends to be fewer side effects and you are able to have a better quality of life.

The following drugs and drug combinations may be used for maintenance therapy for transplant eligible multiple myeloma:

• lenalidomide (Revlimid)
• bortezomib (Velcade)
• lenalidomide and bortezomib
• ixazomib (Ninlaro)

Find out more about targeted therapy for multiple myeloma.

Supportive therapy is used to prevent or control health problems and complications related to multiple myeloma. You may have the following supportive therapy drugs during the 3 phases of treatment for transplant eligible multiple myeloma.

Drugs to slow down bone loss– Everyone with multiple myeloma is usually given either a bisphosphonate, such as zoledronic acid (Aclasta, Zometa) or pamidronate, or a drug called denosumab (Prolia, Xgeva and biosimilars) . These drugs help to slow down bone loss and keep your bones strong.

Drugs to prevent blood clots– Lenalidomide and thalidomide can increase your risk of serious blood clots. You will be given drugs that help prevent blood clots, such as acetylsalicylic acid (ASA, Aspirin), heparin or warfarin, if your treatment includes lenalidomide or thalidomide.

Drugs to prevent infection– Stem cell transplants and drugs used for induction therapy increase your risk of infection. Antibiotics are often given during induction therapy and at the time of a stem cell transplant to help prevent infection.

Find out more about supportive therapy for multiple myeloma.

You may be asked if you want to join a clinical trial for multiple myeloma. Clinical trials look at new ways to prevent, find and treat cancer. Find out more about clinical trials.

You may want to consider a type of care to make you feel better without treating the cancer itself. This may be because the cancer treatments don't work anymore, they're not likely to improve your condition or they may cause side effects that are hard to cope with. There may also be other reasons why you can't have or don't want cancer treatment.

Talk to your healthcare team. They can help you choose care and treatment for advanced cancer.