Relapsed Multiple Myeloma

If your doctor tells you that you're having a relapse, it means your multiple myeloma came back after your treatment left you cancer-free for a while. If this happens to you, keep in mind that there are still treatments that can help. It's a matter of finding the drug or combination of drugs that works for you.

Multiple myeloma can relapse once or a few times. When you first learn about it, you'll have lots of questions about what it means for you. Your doctor will guide you through your next steps. Also reach out to family and friends who can give you the support you need to handle the wave of different emotions you may feel.

What Is Relapsed Multiple Myeloma?

Multiple myeloma affects infection-fighting white blood cells called plasma cells in your bone marrow. Abnormal plasma cells multiply too quickly and crowd out healthy red blood cells and white blood cells.

Chemotherapy and other treatments kill multiple myeloma cells and put you into remission, which means your tests no longer show any signs of cancer. Relapsed multiple myeloma is when the cancer comes back after you were in remission.

Causes

When you're in remission, you won't have any symptoms of multiple myeloma, but a few abnormal plasma cells still remain in your body. Treatments can't kill every single cancer cell. There just may be too few abnormal cells for tests to spot.

Cancer cells that are left behind can become active again and start to multiply. Most people with multiple myeloma eventually relapse.

Symptoms

When you have a relapse, multiple myeloma symptoms can appear again after you've been symptom-free for months or years. You may have the same problems as the first time you were diagnosed, or have different symptoms.

Symptoms of relapsed multiple myeloma may include things like:

  • Bleeding
  • Bruising
  • Tiredness
  • Weakness
  • Infections
  • Bone pain

See your doctor if you have these or any other unusual symptoms.

Getting a Diagnosis

Your doctor will learn that you have relapsed multiple myeloma if your symptoms start up again after a period of being symptom-free. They'll also make a diagnosis if your blood or urine tests show high levels of myeloma protein, which the cancer cells release.

Other tests that can help your doctor figure out that you're having a relapse are:

  • Bone marrow tests
  • Imaging tests such as an X-ray, CT scan, or MRI
  • Genetic testing

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Questions for Your Doctor

Once you're diagnosed, your doctor will put you on a new treatment plan. Make sure you understand why your doctor wants to go that route and what you can expect once your therapy starts.

Ask your doctor questions like:

  • Why did you recommend this treatment?
  • How might it help my cancer?
  • What side effects can it cause?
  • How can I manage any problems that I get from the treatment?
  • When should I see you again?
  • Where can I go for support?

Treatment

The less time you were in remission, the more fast-moving your cancer is and the more intensely it needs to be treated. Other things that help your doctor decide which treatment you get are:

  • How many treatments you've already had
  • Which cancer drugs you took
  • How well the medications worked

Your doctor may suggest you take a combination of two or three drugs. You might get the same medicines you took when you were first diagnosed with multiple myeloma, or different ones.

Some drugs that doctors commonly recommend are:

Proteasome inhibitors. Proteasomes are enzymes inside cells that help break down and remove damaged or unneeded proteins. Multiple myeloma cells make large amounts of abnormal proteins.

Medicine called proteasome inhibitors prevent myeloma cells from breaking down these proteins. As the proteins build up, the cancer cell swells until it finally bursts open and dies.

Proteasome inhibitors include:

Some common side effects from these drugs are:

  • Nausea and vomiting
  • Diarrhea or constipation
  • Fever
  • Tiredness
  • Low blood cell counts
  • Nerve damage

Immunomodulatory drugs. These medications boost your immune system -- your body's defense against germs -- to help it fight the cancer. They also cut off the cancer's blood supply to "starve" it. The medicines include:

Some common side effects that could happen to you are:

  • Tiredness
  • Constipation
  • Nerve damage
  • Low blood cell counts

Steroids. These drugs bring down inflammation in your body and kill myeloma cells. They also ease nausea and vomiting that you might get from chemotherapy.

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Steroids that treat multiple myeloma include:

You might get side effects such as:

  • Weight gain
  • Increased appetite
  • Weak bones
  • Mood changes

Monoclonal antibodies. Your immune system makes antibodies to help it fight germs. Monoclonal antibodies are man-made versions that target proteins on the surface of cancer cells.

The FDA has approved two monoclonal antibodies to treat multiple myeloma:

You get these medicines as an infusion into a vein.

Some people have a reaction to the infusion that includes symptoms like:

  • Trouble breathing
  • Wheezing
  • Coughing
  • Tightness in the throat
  • Dizziness

Other side effects from monoclonal antibodies are:

  • Tiredness
  • Nausea
  • Back pain
  • Fever
  • Diarrhea or constipation
  • Nerve damage

Histone deacetylase inhibitors. These drugs turn on certain genes inside the cancer cells to slow their growth. The FDA has approved one of them, panobinostat (Farydak), to treat multiple myeloma.

It can cause side effects like:

  • Diarrhea
  • Nausea and vomiting
  • Decreased appetite
  • Tiredness
  • Swelling in the arms or legs
  • Nerve damage
  • Low blood cell counts

Chemotherapy . This type of medicine kills cancer cells or slows their growth. If you relapsed more than a year after you finished treatment, your doctor might give you the same chemo drug you took before.

Examples of chemo drugs that treat relapsed multiple myeloma include:

Chemotherapy can cause side effects like:

  • Hair loss
  • Appetite loss
  • Nausea and vomiting
  • Mouth sores
  • Infections
  • Bruising or bleeding

Selective Inhibitor of Nuclear Export (SINE). This is a new class of drugs that is for adult patients who have had four therapies or more and have relapsed. It works by suppressing protein movement from the nucleus of the cancer cell.

There is currently only one in this class:

It is used in combination with the corticosteroid dexamethasone (Decadron).

Possible side effects include:

  • low white cell count
  • nausea and vomiting
  • diarrhea
  • fatigue
  • fever
  • weight loss
  • constipation
  • upper respiratory tract infections

Stem cell transplant. High-dose chemotherapy kills large numbers of cancer cells, but it also damages the stem cells in your bone marrow that grow into new blood cells. A stem cell transplant replaces damaged stem cells with healthy ones taken from your body or from a donor.

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Taking Care of Yourself

Talk to your doctor if your cancer and its treatment leave you with problems like pain, fatigue, and shortness of breath. They can suggest medicine that can help you manage these symptoms.

There are also things you can do on your own to help yourself feel better:

Adjust your diet. Work with a dietitian to make sure you get enough protein and other nutrients, especially if you have nausea or diarrhea. Large meals might be too much for you to digest right now. Instead, eat smaller portions during the day. Also drink lots of fluids to stay hydrated.

Exercise. You might think it goes against common sense, but physical activity can boost your energy and fight fatigue. Check with your doctor to find out which workouts are safest for you.

Try mind-body techniques. Meditation, deep breathing, yoga are some things you can try to relieve tiredness and stress. Acupuncture helps with both fatigue and nausea.

What to Expect

New drugs like the protease inhibitors have given doctors new tools to treat relapsed multiple myeloma. Although your cancer can't be cured, you can manage it with medicines and continue to enjoy your family, friends, and the activities you like to do.

Everyone with multiple myeloma is different. How your disease affects you depends on things like:

  • How fast your cancer is growing
  • The makeup of your tumor
  • Your age
  • Your general health
  • How well your treatment works

Getting Support

If your multiple myeloma or your treatment starts to bring on stress, turn to the people closest to you. Family and friends are usually looking for ways to help, but they often don't know what's the best thing for them to do. Give them specific ideas on how they can pitch in.

You can also get professional advice and support from a counselor or therapist. Ask the doctor who treats you to recommend someone who works with people with multiple myeloma.

Think about joining a support group. You'll meet people who know exactly what you're going through and can offer ideas that have worked for them. Check with organizations like the International Myeloma Foundation and American Cancer Society for suggestions.

WebMD Medical Reference Reviewed by Laura J. Martin, MD on October 14, 2019

Sources

SOURCES:

American Cancer Society: "Drug Therapy for Multiple Myeloma," "Tests to Find Multiple Myeloma," "What is Multiple Myeloma?"

Annals of Oncology: "Multiple myeloma: ESMO Clinical Practice Guidelines for diagnosis, treatment, and follow-up."

ASCO: "Dealing with Cancer Recurrence," "Diarrhea," "Fatigue," "Five Questions Can Guide the Treatment of Relapsed Myeloma," "Multiple Myeloma: Types of Treatment," "Nausea and Vomiting."

Blood: "How I treat first relapse of myeloma."

Cancer Treatment Reviews: "Clinical characteristics of patients with relapsed multiple myeloma."

Get Palliative Care: "Multiple Myeloma and Palliative Care."

Hematology, The Education Program: "Relapsed multiple myeloma."

International Myeloma Foundation: "Dexamethasone and Other Steroids," "Relapse."

Medscape: "Immunomodulatory Drugs in Multiple Myeloma."

Multiple Myeloma Research Foundation: "Multiple Myeloma Treatment Overview," "Prognosis."

MyelomaCrowd: "Myeloma 101: How Immunomodulators Work in Multiple Myeloma," "Myeloma 101: How Proteasome Inhibitors Work," "Myeloma 101: Relapsed and Refractory Myeloma Defined."

Myeloma UK: "Infopack for relapsed and/or refractory myeloma patients."

William E. Kahlert Regional Cancer Center: "Recurrent Multiple Myeloma."

UpToDate: "Patient education: Multiple myeloma treatment (Beyond the Basics)."

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