Multiple myeloma is a type of blood cancer that originates in plasma cells, which are a type of white blood cell found in the bone marrow. These plasma cells normally produce antibodies to help the body fight infections. In multiple myeloma, abnormal plasma cells multiply uncontrollably in the bone marrow, crowding out healthy blood-forming cells and producing dysfunctional antibodies called M proteins or paraproteins. These abnormal proteins and the accumulation of cancerous plasma cells can lead to various health problems. This article will explore a more advanced stage of this condition, known as relapsed/refractory multiple myeloma.
Understanding Relapsed and Refractory Multiple Myeloma
Relapsed multiple myeloma describes the return of disease activity after a period of remission or improvement following previous treatment. The International Myeloma Working Group (IMWG) defines relapse based on specific increases in myeloma activity, detected through measurements in blood, urine, or bone marrow.
Refractory multiple myeloma indicates that the cancer has not responded to ongoing treatment, or it has progressed despite current therapeutic efforts. In some cases, the cancer may not respond to initial treatment, a situation called primary refractory multiple myeloma. Alternatively, it might initially improve but then become resistant to the treatment and begin growing again.
Recognizing the Signs and Diagnosis
The signs and symptoms of relapsed or refractory multiple myeloma often mirror those experienced at initial diagnosis, or they may present differently. Common indicators include increased bone pain, which can occur in areas like the hips, back, or skull, and generalized fatigue. Patients might also experience shortness of breath, or recurrent infections due to a compromised immune system. Nerve damage, known as peripheral neuropathy, can lead to tingling and numbness in the hands or feet.
Diagnosis of relapsed/refractory multiple myeloma involves a range of tests to confirm disease progression. Blood tests measure levels of M-protein (monoclonal protein) and free light chains, which are abnormal proteins produced by myeloma cells. Urine tests also check for these proteins, as well as creatinine levels, which can indicate kidney issues. Bone marrow biopsies are performed to examine the percentage of plasma cells and assess genetic abnormalities within the bone marrow. Imaging studies, such as MRI, PET/CT scans, and low-dose whole-body CT scans, help identify new or worsening bone lesions and assess bone marrow involvement.
Treatment Approaches for R/R Multiple Myeloma
Treatment strategies for relapsed and refractory multiple myeloma are individualized, considering factors like prior therapies, the patient’s overall health, and specific disease characteristics. Various drug classes are employed, often in combination, to target cancer cells.
Immunomodulatory drugs (IMiDs), such as lenalidomide and pomalidomide, work by affecting the immune system and blocking pathways that support myeloma cell growth. Proteasome inhibitors (PIs), including bortezomib and carfilzomib, disrupt cellular processes within myeloma cells, leading to their demise. Monoclonal antibodies, like daratumumab, target specific proteins on the surface of myeloma cells, directly killing them and enhancing the body’s immune response. These agents are frequently combined with corticosteroids like dexamethasone.
Emerging therapies offer new avenues for patients with relapsed/refractory disease. Bispecific antibodies, such as teclistamab, elranatamab, and talquetamab, are engineered to connect myeloma cells to T-cells, activating the immune system to attack the cancer. Teclistamab, for instance, targets BCMA on myeloma cells and CD3 on T cells, leading to an immune attack. CAR T-cell therapy involves collecting a patient’s own T-cells, genetically modifying them in a lab to recognize and attack myeloma cells (often targeting BCMA), and then reinfusing them into the patient. Examples include ciltacabtagene autoleucel and idecabtagene vicleucel. Clinical trials also offer access to novel treatments and combinations, providing additional options for patients who have exhausted standard therapies.
Living with R/R Multiple Myeloma
Living with relapsed/refractory multiple myeloma involves supportive care to manage symptoms and treatment-related side effects. Patients experience symptoms such as bone pain, fatigue, and peripheral neuropathy. Pain management may involve medication, while fatigue can be addressed through planned rest times and appropriate exercise.
Emotional and psychological support is also important, as coping with a chronic and relapsing condition can be challenging. Self-management workshops and educational sessions can help patients understand their condition better and develop coping mechanisms. Support groups provide a community where individuals can share experiences and gain insights from others facing similar challenges. A multidisciplinary care team, including social workers, physical therapists, psychologists, and nutritionists, contributes to a holistic approach to patient care, addressing various aspects of well-being beyond just medical treatment.