Introduction
Treatment decisions for myeloma depend on:
- Presence or absence of symptoms
- General performance status of the patient
- Stage of disease
- Individual patient preference
There are a number of effective treatments for myeloma but despite this, myeloma remains an incurable disease. Following a period of remission, all patients relapse because residual myeloma cells persist even when treatment has been successful. Further treatment is necessary when relapse occurs. The course of myeloma is therefore defined by a pattern of recurrent remission and relapse. Remission periods often become increasingly shorter with subsequent treatments because of the development of more resistant myeloma cell clones. Patients ultimately become refractory (resistant) to any further treatments, and when no other realistic options exist, survival time is shortened and end-of-life care must be considered.
A small minority of patients are, however, refractory to standard treatment from the outset. For these patients, various strategies are in place and clinical trials involving new drugs provide an important option.
Treatment for myeloma is often effective when drugs with different, but complementary, actions are given together. Current strategies therefore aim towards regimens that use combinations of different myeloma treatments. However, some newer immunotherapies are used as monotherapy.
The treatments available at the various stages are based on data derived from clinical trials and consensus of expert opinion. UK treatment options follow guidance set out by the National Institute for Health and Care Excellence (NICE) in England, the All Wales Medicines Strategy Group (AWMSG) in Wales and the Scottish Medicines Consortium (SMC) in Scotland. Northern Ireland usually follows NICE guidance. This means that different drugs are available within the constraints set out by these regulatory bodies and these regimens are the ones we focus on in this chapter. Additional treatment combinations can also be available to certain patients prior to routine use via the Cancer Drugs Fund in England and the National Cancer Medicines Advisory Group (NCMAG) in Scotland. Nurses need to be aware of these to inform their conversations with patients, especially in situations where certain treatments are not approved for NHS use.
In general, the aims of treatment are to:
- Reduce the levels of myeloma as far as possible
- Control the myeloma for as long as possible
- Relieve the symptoms and reduce complications of myeloma
- Maximise quality of life
- Control the myeloma if it has come back again (relapse)
- Prolong survival
Therefore, management of myeloma involves treating the disease itself, alongside supportive therapy to manage the complications of myeloma and side effects of treatment.