Multiple Myeloma Treatment Approaches
Just as every patient is different, we recognize that every multiple myeloma case is different. What distinguishes City of Hope in the treatment of patients with blood disorders is seamless continuity of care. From a new diagnosis to treatment with the newest drugs and stem cell transplantation within our extensive program of myeloma clinical trials, patients are treated by the same team of doctors who see them through every phase of treatment and recovery. City of Hope also offers the expertise of geriatric oncologists who specialize in the treatment of older patients.Treatments vary depending on the specific type of myeloma, and other factors such as the patient’s age, overall health and prior therapy.
 
  • City of Hope is a national leader in transplant trials and heavily involved in new drug trials, including a recently approved novel agent for myeloma (Carfilzomib).
 
  • We are opening a trial conceived at City of Hope combining the newest approved agent Pomalidomide with Ixazomib, a new-generation proteasome inhibitor that is not yet approved for myeloma.  We have been testing this drug in other combination trials and have found it to be well tolerated and efficacious. Hence the combination offers some of the most active agents for relapsed myeloma in a all oral regimen.
 
  • City of Hope runs one of the largest and most successful hematopoietic cell transplantation (HCT) centers in the world. Since 1976, City of Hope has performed more than 11,000 transplants with excellent outcomes for patients from virtually every state and around the world.
 

Chemotherapy

Chemotherapy is considered the first-line treatment for myeloma. Because myeloma is a cancer of the blood and bone marrow, surgery is not an option. Chemotherapy is known as a “systemic” treatment (delivered throughout the body).  Powerful drugs are needed to destroy myeloma cells. These may be given orally or intravenously through an IV or catheter.
 
Chemotherapy is administered in cycles. Some drugs for myeloma are given daily, with each month considered a full cycle. Others are given intermittently over a three-week period. There is usually a rest period between cycles to allow the patient’s blood cell counts to recover.
 
Treatment for myeloma usually involves combinations of agents such as lenalidomide, an immunomodulatory agent for newly diagnosed patients, pomalidomide for relapsed myeloma, and proteasome inhibitors such as bortezomib and carfilzomib.
 
 
The premise behind stem cell transplantation for myeloma is that higher doses of chemotherapy kill more malignant cells. However, other normal cells in the bone marrow are also destroyed. Stem cell transplantation allows delivery of high-dose chemotherapy that ablates or wipes out the bone marrow, followed by rescue with reinfusions of stem cells either from the patient or from a donor.
 
Studies have shown that stem cell transplantation with high-dose chemotherapy increases the response rate and survival in myeloma patients compared with traditional chemotherapy alone.
 
Autologous Stem Cell Transplantation
In autologous (self) transplants, a patient’s own stem cells are collected and frozen ahead of time. Typically, stem cells are collected from peripheral blood. After the cells have been stored, intensive chemotherapy and/or radiation treatments are given to destroy any cancer cells remaining in the body. Then, the healthy stem cells are infused back into the patient.
 
As these new stem cells grow, they restore the body's own blood cells. This type of procedure is commonly used for patients with myeloma after a few months of “induction” (initial) chemotherapy. Myeloma is the leading indication for this type of transplant in the United States. City of Hope is following the lead of many centers and performing this procedure in the day hospital. This allows patients to maintain a more normal quality of life and balance during their transplant rather than being confined to a transplant unit.

Allogeneic Transplantation
In some situations, an allogeneic transplant strategy is preferred, especially if the autologous transplant fails to control the disease. Allogeneic transplants use stem cells from a matched donor. Sometimes, a sibling is an ideal donor but, in many cases, a matched unrelated donor with a similar genetic type as the patient will be used.
 
Researchers now understand that the new immune system carried within the transplanted donor stem cells may help fight the cancer. This is known as the graft-versus-tumor effect, and is important in transplants for myeloma.
 
Ways to reduce allogeneic transplant-related complications are being studied, including less intensive non-myeloablative strategies (“mini-HCT” or “mini transplant”). These have a reduced risk of side effects because the initial chemotherapy or radiation doses are much lower. The success of this kind of transplant depends in part on the graft-versus-tumor effect of the donor stem cells.
 

Radiation therapy uses high-energy X-rays or other types of radiation to kill cancer cells or keep them from growing. As part of a transplant regimen for myeloma, traditional external beam radiation was found to be inferior to chemotherapy alone due to the radiation’s toxicity. However, newer, less toxic radiation technologies may be more effective, and are being explored in clinical trials.
 
City of Hope was the first to use the Helical TomoTherapy System  in myeloma transplant treatments. This system combines radiation delivery with real-time imaging, allowing doctors to create a higher energy dose that targets bone marrow more precisely. The system reduces unwanted exposure of normal tissues and may reduce potential complications.