Myeloma: The right treatment for you

Myeloma treatment often relieves the symptoms of the terminal bone marrow condition. However, the process needs to be carefully considered before going ahead due to the condition's nature. Also known as multiple myeloma, because it affects different areas of the body like the skull, spine and pelvis, it acts in unique ways depending on the individual patient.

A patient's healthcare team will look at some key factors before deciding what treatment to start with. These are:

• The type of myeloma you have
• Your age and fitness
• Anticipating the medication that is available at certain times
• Clinical trials
• What happens at relapse
• Patient preference
• The impact of COVID-19

Expert consultant haematologist, Dr Jaimal Kothari talks about these different aspects and how they are key to ensuring patients with myeloma receive the treatment that is best for their ongoing quality of life.

Why does treatment depend on the type of myeloma you have?

Based on experience, myeloma does not behave in a uniform way. Every patient is unique and can have varying responses to treatment and although the average length of time that someone lives from beginning their treatment is five to seven years, 30 to 40 per cent of all patients will live for more than 10.

Also, its behaviour and whether it's easy or difficult to control are determined by the underlying genetics of the myeloma. As a result, your consultant may recommend a particular class of chemotherapy which may determine whether you are treated with a three or two-drug combination.

How is age and fitness a factor in myeloma treatment?

They are crucial cogs in all healthcare decisions. Most patients will have at least one or two other concurrent medical conditions as myeloma generally affects older people. These conditions have to be taken into account because it's been found that over many years that myeloma treatment isn't tolerated as well by them. They tend to have more side effects from treatment and have more interruptions, which means that medical therapy is not as effective.

Patients that are suitable to have, and are likely to undergo, autologous stem cell treatment (ASCT), are generally under 70 to 75 years of age, in good physical health and have a specific combination of drugs.

What does it mean if medication is only available at certain times?

It has been fantastic to see an increasing number of effective treatments that have become available over the last few years. However, it has made decision making more complex. Certain drugs and combinations are only available at certain times. For example, if certain pre-requisites are met, it can be used for second-line treatment (which happens after initial treatment, known as first-line treatment, has failed, stopped working or has side effects that aren't tolerated) only. It means that clinicians often have to think ahead and consider what gives them the best options for the patient at various time points in the illness. For a number of reasons, this is a complex and inexact science for a number of reasons. Each year, options change and other factors may affect a patient's health that a proposed future treatment becomes unviable.

The healthcare team looking after the patient will, without compromising the actual treatment you may be due to start, always strive to keep as many options open at each time point.

How do clinical trials affect myeloma treatment?

Their potential availability in your hospital is a crucial factor in determining what treatment is recommended. For example, it could be the case that an open trial (such as a new combination of drugs, where a fourth newer drug is added to an existing well-known group of three) for a specific type of myeloma allows the patient the benefit of medication that may not become regularly available for years to come.

Trials have risks as well as potential benefits, however, and new drugs can sometimes cause problems that haven't been heard of before. It's important that whenever the patient is due to begin a new line of myeloma treatment, they should ask their consultant if there is a clinical trial available for them either in their local hospital or a larger hospital in a nearby city.

There will be detailed information for you to read at each trial, so that you have a good understanding of the benefits and risks involved before you decide to consent.

When relapse occurs, how is myeloma treatment affected?

Newer/alternative treatments may become available at different points in a patient's myeloma journey, which is a reflection on what has regularly occurred over the last few years. Their toxicities (side effects) overlap and when planning subsequent treatments, newer treatments need to be taken into consideration. Some people experience cumulative toxicities from prior treatments, for example: neuropathy. They may also get affected by other health concerns, which can make it more complex in planning and delivering treatment. This will require careful discussion with the patient's treatment team.

Maintaining and maximising quality becomes even more important as later treatments, like third, fourth and fifth-line treatments tend to work less effectively than earlier ones. 

Why does patient preference affect myeloma treatment?

Before anything, no one factor discussed in this article will take priority. It can often be a delicate balancing act which can require changing chemotherapy doses as cycles go on and reviews of treatment goals over time.

However, what is absolutely crucial is the patient’s views and needs take centre stage when making these decisions. It may well be that a particular type of treatment is recommended but, if, for example, a patient is keen on having oral treatment only, this could be an option. It may not be as effective or equally, it could. The patient hopefully has time to discuss the pros and cons of different options with your consultant.

How has COVID-19 affected myeloma treatment?

Patients and families have experienced an extremely difficult time. Making decisions during the pandemic has been fraught with many uncertain considerations. It has meant that clinicians have been required to balance various situations including:

• Disease-related factors

For example, 'Can we hold off treatment for now, to reduce the risk of serious COVID-19 illness?'

• Treatment-related factors

'Can disease control be maintained but change or experience a reduction in doses?'

• Patient-related factors

Questions like 'Are there additional non-myeloma reasons that a patient might be at increased risk of COVID-19?'

Shielding and the marked geographical differences in the spread of COVID-19 has also played a part. The hope of further treatments and vaccines, as we move through 2021, have provided some cautious optimism. However, COVID-19 is having a significant impact on patient's treatment. We will better understand the impact of these pandemic-related decisions over time, but clinicians everywhere are balancing minimising risk with attempting to try and use the most up-to-date data to allow optimal decisions.

In summary, the myeloma treatment landscape continues to evolve. The inexact science of decision making, disease factors and availability of treatments all interact with one another.

Provision of the best, bespoke treatment for patients at any point in their treatment journey is our aim. Patients should always be at the heart of the decision-making process and we hope that you get the time to discuss all of this with your healthcare team.

Looking for myeloma expertise that can assist you? Visit Dr Kothari's Top Doctors profile, here, to arrange an appointment