Ask The Nurse // 11th August 2021
Myeloma is a treatable but incurable cancer. This means that for most patients, even after successful treatment, the myeloma will come back (relapse). For many patients, relapses, especially the first relapse, can be just as challenging as an initial diagnosis, and in some ways harder, as patients know they have to face hospital visits, tests and treatment again. There are several treatment options available to patients at first relapse. Although it’s a real positive to have a range of options, the decision of which treatment to have can add stress to an already disappointing situation.
In this month’s blog, we answer some of the questions we are often asked about the first relapse, the treatments available, and how to make treatment decisions.
When should I start treatment?
There are no strict criteria for starting treatment at relapse and the timing of treatment might differ between patients. For example, patients with aggressive or high risk myeloma are more likely to start treatment promptly at the first signs of relapse.
In general, patients start treatment when their myeloma is considered active as confirmed by blood test results, imaging and/or a bone marrow biopsy.
It is important to note that an increase in paraprotein or light chain levels doesn’t necessarily mean that the myeloma is active. Paraprotein and/or light chain levels are very individual and can fluctuate up and down, so a haematologist will look for trends in the results and the presence of other symptoms and or complications (e.g. anaemia, new or increasing pain, fatigue or reduced kidney function) to confirm that a patient is relapsing.
How will my myeloma be treated at first relapse?
The type of treatment offered will depend on your individual circumstances. It will be based on your previous treatment, any side effects experienced, the nature of your myeloma, your overall health, and your preferences.
There are several treatments approved for use through the NHS at first relapse (second line). The treatments include:
- Daratumumab (Darzalex®), bortezomib (Velcade®), dexamethasone
- Lenalidomide (Revlimid®) and dexamethasone
- Carfilzomib (Krypolis®) and dexamethasone
- Carfilzomib, lenalidomide and dexamethasone
- High-dose therapy and stem cell transplantation
There are also two additional options for oral/tablet-based treatments (currently approved for later relapses) which are temporarily available at first relapse due to the COVID-19 pandemic:
- Pomalidomide (Imnovid®) and dexamethasone
- Ixazomib (Ninlaro®), lenalidomide and dexamethasone (England, Wales and Northern Ireland only)
There may also be the option of joining a clinical trial, which can give you access to new and/or innovative treatments,
Why am I being offered a different treatment when my previous treatment worked?
Most patients will get a new combination of drugs at each relapse because myeloma can become resistant to treatment. This is particularly true when the previous treatment has been given continuously until relapse.
To learn more about why this happens, you can watch our video “Clonal evolution: the changing nature of myeloma”
Sometimes, patients will be retreated with a drug they had been given before (e.g. bortezomib). In these cases, the treatment is often combined with a drug(s) they haven’t had before.
How do I decide which treatment is best for me?
Choosing between treatments can be challenging. However, you don’t need to make the decision alone.
We would recommend you start by talking to your haematologist to find out which treatments are suitable for you, which treatment they would recommend and why.
Although effectiveness is often the most important factor when choosing a treatment, there is limited data directly comparing treatments, so you may want to consider the treatment practicalities (e.g. frequency, method of administration) when talking to your haematologist.
It is important to remember that there is no right or wrong decision when it comes to choosing treatment. All of the treatment options have been approved for use and are considered effective.
You can download the “Infopack for relapsed and/or refractory myeloma patients” for more information about relapse.
If you have any questions about relapse or treatment options you can contact us on the Infoline (0800 980 3332 (UK) or 1800 937 773 (Ireland)) or through the Ask The Nurse email service.
The Myeloma Information Specialists