Deciding that treatment is necessary is the most important initial decision. Since all treatments have both short and long-term side effects, treatment must be medically necessary, meaning that "CRAB" or related features are impacting the patient via bone damage, kidney or heart failure, recurrent or serious infections, or nerve/neurologic damage. Additionally, benefits must far outweigh unwanted side effects. Treatment ideally should begin when the trend of active disease is clear, but before major or irreversible damage has occurred.
There are two treatment philosophies, one centered on control of the disease and one focusing on a cure:
- Control therapies aim to achieve long-term disease control and maximum quality of life. With the introduction of novel drugs, such as Thalidomide, Velcade®, Revlimid®, Kyprolis® and Pomalyst® within the last decade, long-term disease control (in remission) is a reality for many patients.
- The goal of cure therapies is a permanent cure that extends beyond the so-called "functional cure," defined as complete remission lasting more than four years. Detailed testing typically reveals that patients in complete remission have small amounts of myeloma remaining, which can lead to relapse. Advocates feel that since it can be months or years until relapse occurs, "functional cure" is a reasonable goal. Precise testing to detect these remaining clones, followed by targeted treatment is the foundation of the IMF’s signature Black Swan Research Initiative®.
Initial therapy can include an autotransplant, or, in some cases, a transplant might not be viable or preferred. Determining factors include age, medical issues besides myeloma, FISH test results and the aggressiveness of the disease. (FOR MORE DETAILS GO TO STEP 5: TRANSPLANTS)
- For transplant patients: pre-transplant two-drug options include Velcade/Dex, Thalidomide/Dex, Rev/Dex, or Cytoxan/Dex. Additional drugs such as VCD, VTD, VRD or V (A/D) D, respectively, might be added to those two-drug combos. Other multi-drug regimens include TT3/4, CTD and TAD. The latest research points to triple therapy with a proteasome inhibitor, which gives superior outcomes.
- Treatment for non-transplant candidates are determined by a patient’s age and fitness. Those who are either fragile or over the age of 75 would continue with a low-dose therapy such as Td, Vd with once-weekly V, Rd, Cd, MP or MPT. Rd on a continuous basis is a new simple option for ongoing disease control especially for patients in this category.
- Fit patients with no non-myeloma medical issues would proceed with IMiD based drugs – MPT, CTD, Rd or MPR.R; or Velcade-based drugs, i.e. VMP, VMPT-VT or VMP-VT. As with fit transplant candidates, triple therapy with a proteasome inhibitor here again gives superior outcomes for fit patients.
- Finally, fit patients with additional medical issues would consider Velcade drugs if there are renal problems, Velcade drugs if there are VTE issues or IMiD therapies if the patient has neuropathy issues.
- It is still very important to limit the use of bisphosphonate therapy (Aredia and Zometa). Osteonecrosis of the jaw is a concern with long term use. Since novel combinations produce deeper response than in the past -- ongoing bone destructions is less often a concern and any survival benefit with very long term Zometa use remains questionable.
©2015 International Myeloma Foundation