Relapsed/Recurrent Multiple Myeloma

Relapsed/recurrent multiple myeloma refers to the return of abnormal plasma cells in the bone marrow after a period of remission. This condition presents unique challenges in treatment and management, requiring a comprehensive approach to care. Multiple myeloma is a type of cancer that affects plasma cells, a crucial component of the immune system responsible for producing antibodies. While advancements in treatment have improved outcomes for many patients, some individuals experience relapsed or recurrent multiple myeloma, presenting unique challenges in management.

Causes of Relapsed/Recurrent Multiple Myeloma

Multiple myeloma is a type of cancer that develops in plasma cells, which are specialized white blood cells responsible for producing antibodies to combat infections.

Following treatment, most myeloma cells in the body are eliminated, but a small number may persist. These residual cells, termed minimal residual disease (MRD), can potentially lead to a relapse when they multiply and divide.

Doctors monitor changes in MRD over time to assess the effectiveness of treatment. Currently, two techniques are employed for MRD measurement: Genetic Sequence Analysis, specifically Next Generation Sequencing (NGS), and Flow cytometry, particularly Next Generation Flow (NGF). It’s important to note that only NGS is approved by the FDA, and ongoing research aims to optimize the use of these tests.

Types of Relapse

There are two categories of multiple myeloma relapse, each requiring different approaches:

1. Indolent or Low-Risk: Progresses gradually over several years. In such cases, your doctor might recommend a previously administered treatment.
2. Aggressive or High-Risk: Develops rapidly, within weeks or months. For this type, your doctor may propose a new therapy option.

Symptoms of Relapsed/Recurrent Multiple Myeloma

1. Bone Pain: Persistent pain in the bones, particularly the back, ribs, and hips.
2. Fatigue: Unexplained tiredness and weakness, even with adequate rest.
3. Anemia: Reduced red blood cell count, resulting in fatigue and weakness.
4. Renal Dysfunction: Impaired kidney function due to the buildup of abnormal proteins.
5. Hypercalcemia: Elevated levels of calcium in the blood, causing symptoms such as excessive thirst and confusion.
6. Recurrent Infections: Increased susceptibility to infections due to compromised immune function.
7. Easy bruising or bleeding
8. Increased urination
9. Nausea and vomiting
10. Unexplained weight loss

Risk Factors for Relapsed/Recurrent Multiple Myeloma

1. Age: Risk increases with advancing age, particularly over 65 years old.
2. Genetics: Family history of multiple myeloma or other plasma cell disorders.
3. Prior Treatment History: Previous exposure to chemotherapy or radiation therapy.
4. Obesity
5. Certain occupational exposures
6. Gender (slightly more common in men)
7. African American descent

Prevalence of Relapsed/Recurrent Multiple Myeloma

1. Global Incidence Rates: Multiple myeloma accounts for approximately 1% of all cancers worldwide.
2. Age and Gender Distribution: More common in older adults, slightly more prevalent in men than women.
3. Trends in Diagnosis: Increasing incidence rates observed in recent years, possibly due to improved detection methods.

Diagnosis

During remission, your doctor will conduct various tests to assess the status of your cancer. These may include:

• Physical examination
• Blood or urine tests
• Computed tomography (CT) scan
• Magnetic resonance imaging (MRI)
• Bone scan
• Bone marrow biopsy

Any abnormal findings from these tests could indicate a recurrence of the condition.

Furthermore, when the disease resurfaces, you may experience familiar issues encountered during your initial diagnosis, or new symptoms may arise. Some common signs and symptoms include:

• Bone pain
• Fractures
• Fever
• Fatigue
• Unexplained weight loss
• Easy bruising
• Difficulty breathing
• Weakness in the arms or legs

Treatments

If you experience a relapse of multiple myeloma, there are several treatment options available, including:

Chemotherapy: This involves the use of medications to kill cancer cells in your body. In the event of a relapse, your doctor may prescribe a higher dose or a different combination of drugs such as Cyclophosphamide, Doxorubicin, Melphalan, Melphalan flufenamide, or Vincristine. High-dose steroids alone may also be considered.

Stem cell transplant: High doses of chemotherapy or radiation used during a relapse can damage the stem cells in your bone marrow. To safeguard these cells, your doctor may perform a stem cell transplant. This procedure involves extracting stem cells, typically from your hip, while you’re under anesthesia. The collected cells are then frozen and reintroduced into your body through a vein following treatment.

Targeted therapies: These medications specifically target certain components of cells involved in the growth, division, or spread of cancer cells. Examples include monoclonal antibodies like daratumumab, elotuzumab, and isatuximab; proteasome inhibitors such as bortezomib, carfilzomib, and ixazomib; immunomodulatory drugs like lenalidomide, pomalidomide, and thalidomide; as well as other drugs like alkylators, anthracyclines, panobinostat, selinexor, and corticosteroids. They may be administered alone or in combination therapy.

Clinical trials: Participating in a clinical trial can provide access to new treatments not yet available through standard care. These studies offer the opportunity to explore innovative therapies for relapsed multiple myeloma.

Supportive care: Your doctor may recommend supportive care to alleviate symptoms or manage complications associated with multiple myeloma. This could include various supportive measures to enhance your quality of life during treatment.

Approximately one-fourth of individuals with relapsed multiple myeloma achieve remission after several cycles of chemotherapy. Those who receive targeted therapies or undergo high-dose chemotherapy followed by a stem cell transplant typically experience better outcomes. Considering a clinical trial may also be a viable option for individuals facing a relapse.

Home Care Remedies

• Maintaining a healthy diet and staying hydrated
• Engaging in regular physical activity to maintain strength and mobility
• Managing pain with over-the-counter or prescription medications as directed by a healthcare provider
• Practicing good hygiene to reduce the risk of infections

What’s the survival rate

Multiple myeloma is seldom curable, so most individuals who undergo treatment will experience a relapse at some stage.

Relapse can occur in the initial site or in other parts of the body.

Patients often go through periods of remission, during which signs of the disease are undetectable on tests, followed by relapse cycles. Your doctor can provide insights into the specific type of multiple myeloma you have.

Prevention

• There are no known ways to prevent multiple myeloma, but reducing exposure to known risk factors such as radiation and certain chemicals may lower the risk of developing the disease.
• During periods of remission, your doctor may prescribe a low dose of maintenance therapy medication, such as a steroid or targeted medicine, for an extended duration. This approach aims to prolong remission and reduce the likelihood of a relapse.
• Although multiple myeloma currently lacks a cure, it’s important to recognize that individuals can live with the condition for an extended period. Moreover, ongoing research and development of new treatment options offer hope for improved outcomes in the future.

When to See a Doctor

• If you experience persistent symptoms such as bone pain, weakness, or unexplained weight loss, it’s important to consult a healthcare provider for evaluation and diagnosis.

Outlook/Prognosis

• The outlook for individuals with relapsed/recurrent multiple myeloma varies depending on factors such as the stage of the disease, response to treatment, and overall health. While relapse can be challenging, many patients continue to live fulfilling lives with ongoing management and support from healthcare professionals.

Sources

1. American Cancer Society. (n.d.). Multiple Myeloma: Statistics.
2. National Comprehensive Cancer Network. (2021). Multiple Myeloma (Version 3.2021).
3. National Institute of Health. (2021). Multiple Myeloma Treatment (PDQ®)–Health Professional Version.
4. WebMD