Relapsed/refractory multiple myeloma (RRMM) refers to two different treatment responses. If your myeloma relapsed, your treatment was successful but the cancer came back. In refractory disease, the myeloma continued to progress either while you were getting treatment or within a couple of months after it.
In both cases, you most likely have more treatment options available to you. But they do come with the risk of sometimes serious side effects. As you and your care team move forward with the next phase of your care, it’s a good idea to understand how doctors decide which treatment to recommend, the side effects of each option, and how you and your care team will manage them together.
Weighing Benefits Against Risks
When your doctor decides which treatment to recommend for you, side effects will be a major consideration. They will try to predict your chances of certain side effects and how well you’ll be able to tolerate them.
They will consider:
- The treatments you’ve already had
- How well those treatments worked
- Your age
- Other medical problems you have
- Lingering side effects from past treatments
- Your personal treatments and goals
These are some of the possible side effects your doctor will discuss with you.
Nerve Problems in the Hands and Feet
Doctors call it “peripheral neuropathy” -- pain, numbness, weakness, or tingling, usually in your hands or feet, that comes from nerve damage. Certain MM drugs, such as proteasome inhibitors, cause this kind of nerve damage.
These nerve problems are less likely if you get the drug as an injection under your skin rather than into a vein through an IV.
Your doctor can also prescribe medicine or recommend over-the-counter vitamins and supplements for nerve pain. But don’t take anything without getting the green light from your doctor first. Even over-the-counter products can cause interactions with your cancer treatment or keep it from working. Physical therapy and acupuncture might help relieve neuropathy, too.
Low Blood Counts
Most of the newer MM drugs come with a greater likelihood of low blood counts. This general term means that you have low levels of red or white blood cells or platelets.
Some of these medicines may decrease the number of platelets you have. Platelets are blood cells that the body makes inside your bone marrow. They clot your blood to stop bleeding if you’re injured. If your platelet count is very low, you have a greater chance of internal bleeding into your stomach, bowels, or brain. It can also raise your risk of having a heart attack.
Some medicines may cause a low red blood cell count, also called anemia. Symptoms include:
- Weakness
- Tiredness
- Shortness of breath
- Fast heartbeat
- Dizziness
- Chest pain
- Swelling of hands, feet, or ankles
- Looking pale
Your treatment may also decrease your white blood cell count. These are the blood cells that fight infections. If they are too low, you may have:
- Increased risk of infections
- Fever and chills
- Sores in your mouth
- Trouble breathing
- Cough
- Pain in your abdomen
Blood Clots
Some MM medications can increase the risk for a blood clot condition called venous thromboembolism. That’s when you get blood clots in a deep vein, usually in your leg or pelvis, which can break free and travel to your lungs.
If you have other risk factors for blood clots when you start taking these drugs, you’ll likely also go on blood thinners to help prevent clots. Some of these risk factors include a personal or family history of clots, smoking, and taking birth control pills.
Heart Problems
Some treatments for multiple myeloma can cause heart problems and lead to:
- High blood pressure
- Fluid retention and swelling in your legs, feet, arms, and hands (peripheral edema)
- Shortness of breath (dyspnea)
- Too little flow of blood and oxygen to the heart (ischemia)
- Heart failure
You’re at greatest risk if you already have high blood pressure when you start treatment or if you are on a higher dose of certain drugs.
Doctors can help lower your chances of treatment-related heart problems by getting all your risk factors, including high blood pressure, under control before you start a new drug. They may also want to watch you more closely and do frequent blood pressure checks while you have your myeloma treatment. They may start you on blood pressure meds if yours goes up while you’re in treatment or adjust your dosage if you already take them.
GI Problems
GI problems are the most common side effects of multiple myeloma drugs. They include:
- Nausea
- Diarrhea
- Throwing up
- Loss of appetite
- Constipation
Your care team will recommend over-the-counter or prescription medicines to treat whichever GI symptoms you’re having. They might also tell you to avoid or add certain foods to your diet. In some cases, your doctor might lower the dose of your cancer medications to help ease these side effects. They might also put you on anti-nausea meds and another medicine to help stimulate your appetite.
If you have any of these problems, it’s important to tell your doctor. Leaving them untreated can lead to more serious problems like extreme weight loss or nutritional imbalances right when you need your strength most.
Eye Problems
Some medications for the treatment of multiple myeloma come with a greater chance of eye problems, specifically in your cornea. Doctors call corneal disease keratopathy, and it can cause these symptoms:
- Blurred vision
- Severe vision loss
- Eye ulcers
- Dry eyes
Before you start these drugs, you’ll have to have an eye exam. You’ll get another one before each dose and again if your vision gets worse.
Other drugs may cause cataracts or make them worse. Check with your doctor right away if you notice any of the following:
- Double vision
- Blurry vision or trouble seeing
- Sensitivity to light or glare
Side Effects of Specific Drugs
Bortezomib (Velcade) can raise your risk for shingles, so you might take pills to prevent it while you’re on this drug.
Lenalidomide (Revlimid), when combined with the chemo drug melphalan, brings a small possibility of causing a second cancer. Your doctor may watch you closely to catch any changes early. You should not get pregnant while you take this drug and for a period of 4 weeks before and after taking it because it can cause serious birth defects or death to your developing baby.
Unique Effects of CAR T-Cell Therapy
CAR T-cell therapy harnesses your body’s immune system to fight cancer. Your immune system may react dramatically and lead to the following problems:
Cytokine release syndrome (CRS). This is when your immune system has a stronger reaction to immunotherapy drugs than is needed. You can get an extremely high fever, nausea, extreme tiredness, and body aches. In short, you’ll feel like you’re very sick with the flu. Doctors need to treat it right away, so report your symptoms immediately.
Neurotoxicity. With this, you’ll feel confusion or brain fog. It can happen during or after CRS.
Infections. While your immune system unleashes all its power on your cancer, it can make you more prone to other infections.
Like most MM treatments, this one can also cause low blood counts.
Because of the likelihood of these serious side effects, you’ll likely stay in the hospital for about a week when you get this treatment, and you’ll need to stay near the hospital for the whole month.
How You Can Help Control Side Effects
Side effects are a common reason for people to have to stop a particular treatment. Before you start a new treatment, make sure to ask your doctor exactly which side effects you should report and how you’ll know that you are having them. Then let your doctor know about any signs of problems as soon as they appear. That way, they can address them and you can continue with your treatment.
Show Sources
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SOURCES:
Cancers: “Management of Adverse Events and Supportive Therapy in Relapsed/Refractory Multiple Myeloma.”
Drugs.com: “Bortezomib dosage.”
American Cancer Society: “Low Red Blood Cell Counts (Anemia),” “Low White Blood Cell Counts (Neutropenia).”
StatPearls: “Bortezomib.”
Penn Medicine: “What is anemia?”
GSKPro: Blenrep package insert.
eClinical Medicine: “Maintenance lenalidomide in newly diagnosed transplant eligible and non-eligible myeloma patients; profiling second primary malignancies in 4358 patients treated in the Myeloma XI Trial.”
Cleveland Clinic: “Cytokine Release Syndrome,” “Thrombocytopenia.”
National Heart, Lung, and Blood Institute: “Thrombocytopenia.”
YouTube: Relapsed/Refractory Multiple Myeloma, Multiple Myeloma Research Foundation.
Medline Plus: “Lenalidomide.”
