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Multiple Myeloma

Our Approach
City of Hope is recognized internationally for its breakthrough research discoveries and clinical treatments for myeloma and other blood disorders.

Our physicians and researchers develop treatments and improve outcomes for patients with myeloma and other plasma cell disorders. City of Hope’s approach to myeloma incorporates our nationally-recognized stem cell transplantation program,with many clinical protocols utilizing the new agents used in treatment of myeloma.

Our patients receive care from a multidisciplinary team of professionals, including hematologists and oncologists, radiation oncologists, nurses, supportive care specialists, dieticians, therapists, social workers, psychiatrists, psychologists and pharmacists. Each member of the team focuses on individual treatment plans designed to extend life, as well as supportive care to improve the quality of life for patients and their families during the treatment period.
 

About Multiple Myeloma

Myeloma is the second most common type of blood cancer. It affects plasma cells, a type of white blood cell that normally helps the body protect itself against infection.

Plasma cells have the ability to produce antibodies, special proteins that fight bacteria, viruses and other invaders that can harm the body

Normally, B-lymphocytes mature into plasma cells. Sometimes, the B-lymphocytes fail to differentiate (or develop) properly into mature plasma cells and form myeloma cells instead. These immature, abnormal cells divide uncontrollably, and become malignant (cancerous). The overabundant myeloma cells begin to crowd out normal cells in the bone marrow, causing problems such as anemia (too few red blood cells), leukopenia (too few white blood cells) or thrombocytopenia (too few platelets that make blood clot).

In the disease called multiple myeloma, malignant plasma cells create multiple tumors (plasmacytomas) within bones and soft tissues. The accumulating plasma cells can lead to bone fractures and increased levels of calcium in the blood. They can also cause problems within organs, especially the kidneys.

Solitary plasmacytomas are another type of plasma cell cancer. Instead of multiple tumors, a single tumor can arise in any part of the body. Most people with a solitary plasmacytoma will eventually develop multiple myeloma, and will require close monitoring.

Myeloma cells also produce an immunoglobulin protein (antibody) called monoclonal (M) protein, or paraprotein. The presence of M protein is a hallmark of myeloma. Unlike a “good” immunoglobulin, M protein does not protect the body. Because levels of normal antibodies are often low in people with myeloma, they can develop frequent infections.

Related Plasma Cell Disorders
Waldenström’s macroglobulinemia is a related disorder in which abnormal plasma cells divide uncontrollably and produce a very large form of M protein. As levels of this protein increase, the blood can become thickened, and the lymph nodes, liver and spleen may become enlarged.

Sometimes before multiple myeloma develops, it is preceded by a condition called monoclonal gammopathy of undetermined significance (MGUS). This condition also involves a slight overgrowth of plasma cells. Although the cells produce excess antibody protein, they do not form a tumor, and do not cause symptoms or health problems. However, many people with MGUS eventually develop multiple myeloma, lymphoma or a disease called amyloidosis. People with MGUS do not require immediate treatment, but should be monitored regularly.

Multiple Myeloma Risk Factors

 
Risk Factors
Although great efforts have been made in myeloma research, to date no cause for this disease has been identified. However, possible associations have been found between myeloma and several other factors:
 
  • Age – more than half of cases arise in people over age 71
  • Male gender – men are 50 percent more likely to develop myeloma than women
  • Black heritage
  • Family history – while most patients have no affected relatives, those with an affected sibling or parent are four times as likely to develop the disease compared to the general population
  • Occupational exposure to certain chemicals, particularly petrochemicals
  • Radiation exposure
  • Obesity – a study conducted by the American Cancer Society found that being obese increases the risk of developing multiple myeloma
  • Other plasma cell diseases such as solitary plasmacytomas and monoclonal gammopathy of undetermined significance
 
Multiple Myeloma Symptoms
Symptoms associated with myeloma include:
 
  •     Pain in the bones, especially the back or ribs
  •     Bone fractures
  •     Weakness, fatigue and a feeling of being unwell
  •     Unusual thirst and frequent urination
  •     Repeated infections
  •     Unusual bleeding, or bruising easily
 

Diagnosing Multiple Myeloma

Initial Tests
Tests and procedures that may be required initially include:
  • Physical exam and history
  • Blood cell counts
  • Blood chemistry tests
  • Urine and blood tests to detect the abnormal myeloma protein
  • Evaluation of a 24-hour urine sample

Bone Marrow Biopsy
To establish a diagnosis of myeloma, a bone marrow aspirate and biopsy are necessary. A biopsy is a test in which a tissue sample is examined under a microscope. A needle is inserted into the hipbone or sternum to obtain a small piece of bone and sample of bone marrow. If there is a solitary plasmacytoma, a biopsy sample may be taken from it for analysis.

If the bone marrow biopsy reveals more than 10 percent plasma cells in the marrow, this condition is known as bone marrow plasmacytosis, and is the determining factor in making a diagnosis of myeloma.

Staging
While establishing a diagnosis of myeloma, doctors need to determine its stage, meaning how advanced the disease has become. This helps in determining prognosis and in treatment planning.There are two staging systems for multiple myeloma. The Durie-Salmon classification system, which classifies myelomas into stages I, II and III, with stage III being the most advanced stage. Patients with stage I disease may not require immediate treatment, while patients with stage II or III disease have active, symptomatic myeloma. Also, the international staging system which uses B2 microglobulin and serum albumin.

Criteria for staging include:
 
  • Blood hemoglobin level – later stages have lower blood hemoglobin as a function of anemia
  • Serum calcium level – higher calcium levels, present in later stages, indicate destruction of bone (osteolysis)
  • Presence of bone lesions – the incidence of bone lesions, visible on X-ray and other imaging tests, increases in later stages
  • M protein production rate – increases in later stages of disease
  • Renal function (as measured by serum creatinine clearance) – decreases as the disease progresses

Imaging Tests
Imaging test used in evaluatingmyeloma:
 
  • X-ray. A skeletal survey is done which is x-rays ofthe major bones.

Multiple Myeloma Treatment Options

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 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.
 
Treatments vary depending on the specific type of myeloma and other factors such as the patient’s age, overall health and prior therapy.

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.
 

Research and Clinical Trials

 
City of Hope is recognized internationally for its breakthrough research discoveries and clinical trials for novel new agents to treat multiple myeloma. We are the only Southern California member of the Multiple Myeloma Research Consortium, a collaboration of the most prestigious research organizations focused on bringing  promising new multiple myeloma treatments to patients.
 
City of Hope has long been a leader in developing promising new combinations of chemotherapy drugs, stem cell transplant procedures and radiation treatments. Current efforts include development of immunotherapy drugs, and we are one of the few institutions to begin T cell trials. With our extensive program of clinical trials, City of Hope can provide our patients access to novel therapies not yet available elsewhere.
 
For patients with relapsed myeloma, multiple treatment options are available, including both standard drugs and novel agents that are being tested in clinical trials.
 
To learn more about our clinical trials program, click here.
 

Multiple Myeloma Resources

All of our patients have access to the  Sheri & Les Biller Patient and Family Resource Center, which offers a wide array of support and educational services. Patients and loved ones may work with a coordinated group of social workers, psychiatrists, psychologists, patient navigators, pain management specialists and spiritual care providers at the center, as well as participate in programs such as music therapy, meditation and many others.

Please visit our Hematologic Cancers and Hematopoietic Cell Transplantation site for additional resources.

Multiple Myeloma Team

Support This Program

It takes the help of a lot of caring people to make hope a reality for our patients. City of Hope was founded by individuals' philanthropic efforts 100 years ago. Their efforts − and those of our supporters today − have built the foundation for the care we provide and the research we conduct. It enables us to strive for new breakthroughs and better therapies − helping more people enjoy longer, better lives.


For more information on supporting this specific program, please contact us below.

Dr. Tina Pakfar
Vice President
Direct: 213-241-7216
Email: tpakfar@coh.org

 
 
What Makes City of Hope Special and other videos
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City of Hope is committed to making the process of becoming a patient here as easy as possible. Call 800-826-HOPE (4673) or complete the Schedule a Callback form.
Our treatment facilities are located throughout our 100+ acre grounds in Duarte, California as well as in  Antelope Valley, South Pasadena, Santa Clarita and Palm Springs.
City of Hope's partnership with the Los Angeles Dodgers, includes ThinkCure!, an innovative, community-based non-profit that raises funds to accelerate collaborative research at City of Hope and Childrens Hospital Los Angeles to cure cancers.
 
The focus of the Division of Hematopoietic Stem Cell and Leukemia Research is to improve the understanding of leukemia stem cells in order to develop cures for leukemia and other hematologic malignancies.
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