When to Treat People With Waldenstrom Macroglobulinemia
While Waldenstrom macroglobulinemia (WM) is generally not considered to be curable, it is treatable. Many different medicines can help keep WM under control, often for long periods of time.
Not everyone with WM needs treatment right away. In fact, some people are diagnosed with WM before they even have symptoms from it. Most experts recommend that people with WM should not usually be treated until the disease is causing problems. This lets people avoid the side effects of chemotherapy (chemo), targeted therapy, or immunotherapy drugs until they really need these medicines. In fact, studies suggest that patients who delay treatment until their WM is causing problems do not live any less time than those who start treatment as soon as they are diagnosed.
Doctors agree that hyperviscosity syndrome is a reason to treat right away, because it can be life threatening. Other reasons to start treatment include problems from amyloidosis or cryoglobulins, as well as anemia (too few red blood cells), kidney or heart problems, nerve damage, or any severe symptom from the WM.
Once a decision has been made to start treatment, there are several options, depending on the patient’s age, general health, and symptoms. Treatment is also based on whether or not the patient might have a stem cell transplant in the future.
Patients with serious symptoms caused by hyperviscosity or with very high levels of IgM protein in the blood might need to be treated with plasmapheresis first to bring the IgM level down. Then treatment with chemotherapy or other drugs can be used to target the cancer cells themselves.
The drugs used to treat WM can be given in a variety of combinations and schedules depending on the situation. Some doctors like to combine drugs (often some type of chemotherapy plus rituximab), while others prefer to start with a single drug. The patient’s age, overall health, and symptoms can also affect which treatments are recommended.
In general, rituximab is not usually given when the IgM level is very high because it can make the IgM level temporarily go up even higher. Plasmapheresis may be used first to lower the IgM level before starting rituximab.
If a stem cell transplant might be used later on, many experts recommend not giving certain chemo drugs (chlorambucil, bendamustine, cladribine, or fludarabine) because they might affect the stem cells in the body.
Some of the drugs and combinations that might be used as the first treatment for WM include:
- Bendamustine, with or without rituximab
- Bortezomib, with or without dexamethasone and/or rituximab
- Cladribine, with or without rituximab
- Cyclophosphamide, doxorubicin, vincristine, prednisone, and rituximab (CHOP-R)
- Cyclophosphamide, prednisone, and rituximab (CPR)
- Fludarabine, with or without rituximab
- Fludarabine, cyclophosphamide, and rituximab (FCR)
- Rituximab, cyclophosphamide, and dexamethasone (RCD)
- Thalidomide, with or without rituximab
Other drugs and drug combinations can also be used. Talk to your doctor about which regimen might be best for you based on your situation.
During treatment, you’ll have regular visits with your doctor, who will ask you about your symptoms, do physical exams, and test your blood to see how well the treatment is working. In most people with WM, the disease will respond to treatment (IgM levels will go down and symptoms will get better) within a few months, although this may take longer in people getting rituximab alone. If a response is achieved, options include close monitoring for signs of disease progression or giving rituximab on a regular schedule to help keep the disease in check.
If initial treatment doesn’t work or if the disease comes back after treatment
No single treatment for WM works for all patients. If the first drug or set of drugs doesn’t work, other drugs may be helpful.
Most people with WM will require treatment with different drugs at some point. Often, a certain drug or combination will work at first, but over time it might stop working. Or a person might stop treatment if the WM is under control, only to have it come back some time later. If the WM remained under control for at least a year after the first treatment, then giving the same drug(s) again can often help bring the cancer back under control.
If the cancer comes back sooner, or if the initial treatment was not effective, then switching to another drug or combination is likely to be a better option. Many of the same drugs and combinations listed above as first-line treatments might be helpful here. Other drugs that might also be tried include alemtuzumab (Campath), ofatumumab (Arzerra), ibrutinib (Imbruvica), or everolimus (Afinitor). High-dose chemotherapy with stem cell transplant might also be an option for some patients.
If chemotherapy or other drugs are no longer slowing the growth of the WM, some patients can still get relief from symptoms by getting plasmapheresis at regular intervals to lower the levels of the abnormal IgM protein in their blood.
Sometimes WM can turn into an aggressive lymphoma. When this happens, the cancer grows much more quickly and causes symptoms that can soon become life threatening. These lymphomas are usually treated with a combination of several chemo drugs like those used for patients who are first diagnosed with an aggressive non-Hodgkin lymphoma (see the treatment section of Non-Hodgkin Lymphoma). If combination chemo is not successful, high-dose chemo with a stem cell transplant may be an option.
Last Medical Review: October 20, 2014 Last Revised: January 28, 2015
- Chemotherapy for Waldenstrom Macroglobulinemia
- Targeted Drugs for Waldenstrom Macroglobulinemia
- Biological Therapy or Immunotherapy for Waldenstrom Macroglobulinemia
- Plasmapheresis (Plasma Exchange) for Waldenstrom Macroglobulinemia
- Stem Cell Transplant for Waldenstrom Macroglobulinemia
- Radiation Therapy for Waldenstrom Macroglobulinemia
- When to Treat People With Waldenstrom Macroglobulinemia