Chemotherapy for Multiple Myeloma

Multiple myeloma (MM) is a hematological cancer that develops in the plasma cells in the bone marrow. These specialized white blood cells produce infection-fighting antibodies (immunoglobulins), which are essential for maintaining the body’s immune function. Through a complex, multistep process that occurs over many years, healthy plasma cells can sometimes transform into cancerous myeloma cells that travel through the immune system to reach various areas of the body.

Chemotherapy is a systemic treatment that uses powerful anticancer drugs to destroy rapidly dividing cells throughout the body, such as myeloma cells in the bone marrow. Because chemo can target widespread cancer cells, it is a common treatment for multiple myeloma.

When is chemotherapy used for multiple myeloma?

Chemotherapy can be used for multiple myeloma in several different stages and settings, depending on the patient’s diagnosis and overall health. Often, it is part of the initial treatment regimen for a newly diagnosed patient, especially if they are not a candidate for a bone marrow transplant. Additionally, for a patient who is eligible for bone marrow transplantation, chemo may be administered as induction therapy to reduce the number of myeloma cells in the body before the procedure and again afterward as consolidation or maintenance therapy.

For relapsed or refractory multiple myeloma, chemotherapy may be used if the cancer has stopped responding to the initial treatment regimen. It can help control the progression of the cancer and alleviate symptoms, such as bone pain and anemia. Although promising new targeted therapies and immunotherapies are currently under development, chemotherapy remains a cornerstone of treatment for multiple myeloma.

What does chemotherapy for multiple myeloma involve?

Chemotherapy for MM may be given orally or through intravenous infusion. In many cases, a combination of drugs is prescribed to increase effectiveness and reduce the risk of side effects. Treatment is typically delivered in cycles, each consisting of an active chemotherapy period followed by a rest period to allow the body to recover and regenerate healthy cells. For instance, a patient may receive chemotherapy daily for one week, followed by three weeks of rest. Most patients undergo multiple rounds of chemotherapy, with each round involving four to six cycles administered over a total of four to six months.

If you suspect you may have myeloma, it is important to come to a high-volume program such as ours at Moffitt, so you can receive multispecialty care for this uncommon cancer.

Dr. Rachid Baz

Malignant Hematology Program

Several chemotherapy drugs can be used to treat multiple myeloma. These include:

• Melphalan – A traditional chemo drug that interferes with DNA replication in cancer cells, melphalan is frequently used as part of high-dose induction therapy or in combination with prednisone or other drugs for a patient who is not eligible for bone marrow transplantation.
• Cyclophosphamide – An alkylating agent that damages cancer cell DNA and prevents cellular replication, cyclophosphamide is often used in induction therapy, paired with newer agents, such as bortezomib and dexamethasone (e.g., CyBorD regimen), or as part of salvage therapy for MM relapse.
• Doxorubicin or liposomal doxorubicin – Doxorubicin is an anthracycline that interferes with DNA and RNA production in cancer cells. Liposomal versions of the drug tend to be better tolerated and are often used in combination prescriptions.
• Etoposide – A less commonly used chemotherapy drug for multiple myeloma, etoposide may be considered in certain salvage regimens for relapsed or refractory cancer.

To reduce inflammation, help manage side effects and improve the patient’s quality of life during treatment, chemotherapy may be combined with corticosteroids, such as dexamethasone or prednisone, and novel agents, such as:

• Proteasome inhibitors (e.g., bortezomib, carfilzomib)
• Immunomodulatory drugs (e.g., lenalidomide, thalidomide, pomalidomide)
• Monoclonal antibodies (e.g., daratumumab, elotuzumab)

The specifics of treatment can vary depending on multiple factors, including the patient’s age, kidney function, co-existing medical conditions, prior treatment response and candidacy for bone marrow transplantation.

What happens during chemotherapy for multiple myeloma?

Chemotherapy for MM is usually administered intravenously in an outpatient infusion center. The chemo drugs can be delivered in several ways, depending on the duration and frequency of treatment. Options may include:

• Cannula – A small, flexible tube is inserted into a vein in the back of the hand or lower arm, a common approach for short-term and single-day treatments.
• Central line – A long, thin catheter is placed into a large vein in the chest, allowing for repeated access over time.
• Peripherally inserted central venous catheter (PICC) line – A long, thin tube is inserted into a vein in the arm and advanced toward a central vein near the heart, offering a less invasive alternative to a chest line.
• Implantable port (portacath) – A soft, flexible tube is tunneled under the skin and connected to a small port placed beneath the skin of the chest or upper arm. A portacath is typically used for long-term treatment.

Once the chosen access device is in place, the chemotherapy drugs may be administered by injection, drip or infusion pump. Each treatment session can last from a few minutes to several hours, depending on the drug combination and dosing schedule. After entering the bloodstream, the medications will travel throughout the body to target and destroy cancerous plasma cells.

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What are the possible side effects of chemotherapy for multiple myeloma?

Chemotherapy for MM can cause a range of side effects depending on the specific drugs used, the dosage and the patient’s overall health. Because chemo affects both cancerous and healthy rapidly dividing cells, side effects are common and may impact different systems in the body. These include:

• Easy bleeding and bruising – A platelet deficiency can make bleeding and bruising more likely, even with minor injuries.
• Constipation or diarrhea – Digestive side effects are common with chemotherapy and can vary in severity based on the specific drug regimen.
• Fatigue – Persistent tiredness and lack of energy can result from reduced red blood cell counts.
• Hair thinning – Some chemo drugs may cause partial or complete hair loss, which is often temporary.
• Increased risk of infection – Chemotherapy can lower white blood cell counts, making the body more susceptible to infections.
• Loss of appetite – Changes in taste or smell perception and digestive issues may contribute to decreased food intake.
• Mouth sores – Painful ulcers may develop in the mouth or throat, making eating and speaking uncomfortable.
• Nausea and vomiting – Gastrointestinal distress may occur shortly after treatment and can usually be managed with anti-nausea medications.

Less common but more serious side effects of chemotherapy for multiple myeloma include:

• Cognitive changes – Some patients report memory loss or difficulty concentrating, sometimes referred to as “chemo brain.”
• Kidney issues – Multiple myeloma and its treatment can affect kidney function, which may require monitoring or intervention.
• Nerve damage (peripheral neuropathy) – Tingling, numbness or pain in the hands and feet are associated with certain chemo drugs.

The patient should promptly report any side effects of chemotherapy to their physician, who can suggest supportive medications and lifestyle adjustments to improve comfort.

What are the risks and possible complications of chemotherapy for multiple myeloma?

Chemotherapy for MM carries certain risks and potential complications beyond the more common side effects. While it can effectively control the cancer, chemo can also affect healthy tissues and organ systems, particularly with prolonged or high-dose use.

Potential complications of chemotherapy for multiple myeloma include:

• Severe infections – Chemotherapy can significantly lower white blood cell counts, weakening the immune system and increasing the risk of bacterial, viral and fungal infections that may become life-threatening if not promptly treated.
• Organ damage – Certain chemo drugs can be toxic to the kidneys, liver, heart or lungs, particularly in a patient who already has organ impairment due to an underlying condition.
• Blood clots – Multiple myeloma and its treatment can increase the risk of developing deep vein thrombosis (DVT) or pulmonary embolism (PE), especially when chemotherapy is combined with steroids or immunomodulatory agents.
• Severe gastrointestinal problems – High-dose chemotherapy can cause intense nausea and vomiting as well as painful inflammation of the digestive tract (mucositis), potentially leading to dehydration and/or nutritional deficiencies.
• Fertility issues – Chemotherapy can affect reproductive function in both men and women, sometimes resulting in temporary or permanent infertility.

During chemotherapy for multiple myeloma, the patient will be closely monitored to help ensure that complications are identified early. The healthcare team will adjust the treatment plan if any significant issues arise.

What to expect during recovery from chemotherapy for multiple myeloma

After receiving chemotherapy for MM, the patient will enter the recovery phase. During this period, the patient will be carefully monitored for treatment side effects. They will also undergo periodic blood testing to track their blood cell levels, kidney function and overall treatment response.

The recovery timeline can vary depending on the type of chemotherapy drugs used and the patient’s overall health and response to treatment. Most patients gradually regain their strength and energy. While some side effects may resolve shortly after treatment ends, others can persist for weeks or even months.

One of the most common challenges faced by patients recovering from chemotherapy is fatigue, which occurs as the body works hard to heal from the effects of this intensive treatment. The patient may also experience lingering nausea, appetite changes and weakness. Because chemo can suppress the immune system, the patient may be advised to take extra precautions against infection, such as practicing meticulous hand hygiene, avoiding close contact with others (especially those who are ill) and following their physician’s guidance on vaccinations and medications to boost immunity.

In some cases, additional treatment may be considered after chemotherapy for multiple myeloma. Options may include supportive medications, blood transfusions and targeted therapies to help manage symptoms and maintain cancer remission. Recovery is an ongoing process that requires careful monitoring and lifestyle adjustments to support long-term health.

How effective is chemotherapy for multiple myeloma?

Chemotherapy for MM can be effective, particularly in slowing the progression of the cancer, relieving the symptoms and enhancing the patient’s quality of life. While not curative for multiple myeloma, chemo can play a key role in controlling cancer cell growth and is often combined with other treatments, such as immunotherapy and bone marrow transplantation, for heightened efficacy.

Many patients respond well to chemotherapy for multiple myeloma, experiencing a significant reduction in cancer cells and entering partial or complete remission. When used as induction therapy before bone marrow transplantation, chemo can help maximize the effectiveness of the transplant by reducing the myeloma cells in the bone marrow.

Chemotherapy can also be used as maintenance therapy to help prolong cancer remission and prevent relapse. That said, multiple myeloma is a chronic condition with the potential to recur, which means that even though chemotherapy may be highly effective, the cancer can still return. If it does, the patient may undergo additional cycles of chemotherapy or switch to a different drug combination. Ongoing advances in treatment, including the development of new chemotherapy agents and combination therapies, continue to improve long-term outcomes and quality of life for patients with multiple myeloma.

Benefit from world-class care at Moffitt Cancer Center

In Moffitt’s renowned Malignant Hematology Program, the treatment options for multiple myeloma continue to expand as our scientists and clinicians perform intensive research and conduct clinical trials to explore promising new therapies. In addition to accelerating the development of new treatment options, we are continually improving the selection process to match each patient with the right approach for their needs and goals.

If you have questions about chemotherapy for multiple myeloma, you can request an appointment with a specialist in the Malignant Hematology Program at Moffitt by calling 1-888-663-3488 or submitting a new patient registration form online. Chemotherapy for multiple myeloma is available at all Moffitt locations, and we do not require referrals.