Craig Cole, MD, is a hematologist-oncologist with Karmanos Cancer Institute and an associate professor in the Department of Oncology at Wayne State University School of Medicine in Detroit. The information shared here represents his expertise in multiple myeloma.
Multiple myeloma is a rare type of blood cancer that happens in certain white blood cells called plasma cells. Experts aren’t clear on why certain people get multiple myeloma, but it’s caused by a genetic mutation that typically happens later in life.
To help you understand more about this cancer and what it means to live with and manage it, hematologist-oncologist Craig Cole, MD, from Karmanos Cancer Institute, shares his expert insights.
What’s happening in the body when you have multiple myeloma?
You have bone marrow inside your bones, and this is your body’s blood factory. Inside your marrow are cells called plasma cells, which make proteins called antibodies to help you fight infection. Just like any other cell in the body can mutate – a lung cell can become lung cancer or a skin cell can become melanoma, for example – a plasma cell inside the bone marrow can mutate, become malignant, and turn into a cancer cell. That cancerous plasma cell may form tumors in several areas of the body, leading to a diagnosis of multiple myeloma. “Multiple” means it goes to multiple places, and “myeloma” means it originates in the bone marrow.
When you have myeloma, several things happen. Because bone marrow is part of your immune system, your immune system becomes weakened. Plasma cells start producing large amounts of abnormal protein when they become cancerous. This protein is called a monoclonal or myeloma protein, and we can detect it in the blood – which is often how we first find myeloma in people.
These plasma cells are tricky because they travel from the bone marrow to other places, like the bones. They can go to multiple areas and cause the bones to weaken and form holes, which leads to pain. People often get back pain, broken bones, or shoulder pain because myeloma cells weaken the bones just as they weaken the bone marrow.
When the bones weaken, calcium can be released into your blood, and higher calcium levels can cause confusion and weakness. Because myeloma crowds out the bone marrow, you can have low red blood counts, or anemia, which causes weakness and fatigue. The abnormal protein made by plasma cells can also get trapped in the kidneys – the body’s filters – leading to kidney damage. This shows up on blood tests as an increased creatinine level.
What causes multiple myeloma?
When patients ask, “Did I cause this?” my answer is absolutely not. We don’t know of anything in today’s environment that causes myeloma. What increases your risk of myeloma more than anything else is getting older. The longer you live, the more your immune system is activated and deactivated, fighting infections throughout your life. Each time this happens, plasma cells are turned on and off, and over time, that can lead to mutations that make them cancerous.
So what causes myeloma? Essentially, living your life and aging. You hardly see myeloma in kids. It’s rare in people in their 30s or 40s, and the usual age of diagnosis is between 60 and 70. Other risk factors include being male – men are more likely to have it – and, for reasons not yet understood, people of African descent have a higher incidence of myeloma than other groups. But what exactly causes it is still something we’re trying to figure out.
How do you decide on a treatment course for multiple myeloma?
The most important step in making treatment decisions is getting a bone marrow biopsy. The bone marrow we use is typically from a pelvic bone near the lower part of your waist, around your belt line, on either the right or left side. We take a small sample of that marrow where the plasma cells live.
From that sample, we can count how many plasma cells are present. Normally, it’s about one percent, but in multiple myeloma when they’re malignant, at least 10% of the bone marrow is made up of abnormal plasma cells. On average, it’s around 30% to 40%. We also look at what mutations have occurred in those plasma cells that caused them to become malignant in the first place. That helps us classify patients as either high-risk or standard-risk.
This distinction matters because all patients with myeloma generally respond to the same treatments in the beginning, but high-risk patients tend to relapse sooner than standard-risk patients. So, with high-risk myeloma, we take additional steps to help prolong remission.
Another way we assess risk is by stage. We use a three-part staging system: stages I, II, and III. Stage III indicates higher risk, and we may take extra measures to ensure the myeloma stays under control.
What is the goal of treatment?
We have three main goals when treating myeloma. First, we want to quickly control or eliminate any immediate problems that the myeloma is causing – like broken bones, bone pain, nerve compression from collapsed vertebrae, kidney damage, or severe anemia. The goal is to improve how people feel right away.
Second, we aim to prolong life. Today’s treatments do an excellent job at this. We want to delay relapse for as long as possible so people can live their lives normally without constantly worrying about myeloma.
Third, because myeloma isn’t yet curable (though we believe it may be in the future), we focus on maintaining a good quality of life while keeping the disease under control. Long-term treatment should allow you to feel well and live fully.
Unlike other cancers where a CT scan can show tumor shrinkage, myeloma improvement is seen in the drop of protein levels in the blood. When those numbers fall to zero, that’s when you know treatment is working.
How can people practice being an active part of their health care team?
The biggest thing is knowing you shouldn’t try to carry all of this on your own. There’s a lot of information and many decisions to make with multiple myeloma. It’s a marathon, not a sprint. Build a team that includes people who can go to appointments with you, take notes, and help if you’re not feeling well or have brain fog. Include a dietitian, your nurses, your doctor, any nurse practitioners or physician assistants they work with, and, if available, a financial counselor or social worker who can help manage medication costs.
Make sure your team members communicate with each other, and keep your own records. After a bone marrow biopsy, keep a copy of the report. Track your lab results – especially your monoclonal protein (M-protein, or myeloma protein) levels.
Before appointments, prepare a list of questions, and always end by asking, “Are there any questions I should have asked?” Doctors hear many of the same questions and can help cover anything you missed.
What are the different types of treatment options for multiple myeloma?
The treatments for multiple myeloma target the disease’s weaknesses from several directions. Immunotherapy uses lab-made antibodies that attach to myeloma cells, helping your own immune system recognize and destroy them. Immunomodulatory drugs, or IMiDs, interfere with the myeloma cells’ connection to the bone marrow – their “home” – cutting off their food source and causing them to die. Proteasome inhibitors work differently; since myeloma cells produce large amounts of protein, these drugs block their ability to dispose of waste from that process. The buildup of waste causes the cells to burst. We also use steroids similar to the steroids given for asthma or poison ivy (such as dexamethasone). Myeloma cells are particularly sensitive to them, making steroids an important part of treatment.
All four of these – antibody therapy, IMiDs, proteasome inhibitors, and steroids – are often combined in what’s called four-drug therapy. Because myeloma weakens bones, we also give other medications such as Zometa or Xgeva, along with calcium and vitamin D to strengthen bone health.
After the initial treatment phase, many people go on to receive high-dose chemotherapy followed by a stem cell transplant using their own stem cells to help the bone marrow recover more quickly. It’s like hitting the myeloma repeatedly with strong punches and then using the transplant as the final strike.
If the myeloma returns, newer options are available, including T cell-redirecting therapies such as CAR T-cell therapy and bispecific antibodies. These treatments harness your immune system’s T cells and direct them to seek out and destroy myeloma cells. Together, these approaches represent the main categories of treatments currently used for multiple myeloma.
What makes you hopeful about the future of multiple myeloma?
I’m very hopeful. I believe we’ve already cured some patients with current treatments, and the pace of progress is incredible. The landscape of myeloma therapy is expanding rapidly, with new and exciting drugs emerging all the time.
We’ve identified the Achilles’ heel of myeloma – it struggles to defend itself against the body’s own immune system, particularly T cells. These T cells are designed to recognize and destroy mutated cells, and now we can harness that natural power with T cell-redirecting therapies like CAR T and bispecifics.
These treatments teach the immune system to destroy the cancer itself, and they’re showing tremendous promise. I believe they’ll not only allow us to keep myeloma in remission for long periods but eventually lead us to a cure.
