Primary refractory myeloma

A small minority of patients do not respond after their first few cycles of initial treatment and their myeloma continues to progress. These patients are said to have primary refractory disease.

For patients who are refractory to a thalidomide-containing treatment, it is recommended they change to a bortezomib-based regimen e.g. VCD. Likewise, patients who are refractory to bortezomib should change to a thalidomide-containing regimen. Entry into a clinical trial should be considered wherever possible.

If patients are still refractory, the combination commonly referred to as DT-PACE (dexamethasone, thalidomide, cisplatin, doxorubicin (Adriamycin ®), cyclophosphamide and etoposide) may be considered. DT-PACE is given continuously over a 4-day cycle through a central line so a patient must remain in hospital throughout. Typically patients require two or more cycles of treatment, each followed by a recovery period. Due to the number of different drugs used, there are a range of side effects associated with this regime. In particular, a reduced immune system leads to increased risk of infection so patients may be kept in isolation and monitored for 28 days after treatment to ensure blood counts return to normal.

Being told that their initial treatment has not worked is worrying and distressing for patients. Nurses therefore have a significant role to play in supporting patients through this period and providing details and clear explanations of available treatment options.