If your myeloma comes back, it may be possible to repeat the treatment that you originally had to control the disease, depending on what the treatment was and how long your remission lasted. If this isn't possible, there are usually other treatment options. Your doctor will discuss all the possible treatment options with you.

Treatments that may be considered are: chemotherapy, high-dose treatment with a stem cell transplant, thalidomide, bortezomib (Velcade®) and steroids.

Bortezomib is a new type of anti-cancer drug called a proteosome inhibitor. It is given to people who have previously been treated with chemotherapy, but whose myeloma has come back or continued to develop despite treatment, and who have already had, or are unsuitable for, a bone marrow transplant.

Proteosomes are a group of enzymes found in all cells in the body. They have an important role in controlling cell function and growth. By interfering with the function of proteosomes, bortezomib may cause cancer cells to die and may stop the cancer from growing. You will be given bortezomib as an injection into a vein. You will usually have four doses over a three-week period. You may also be given a steroid.

Side effects of bortezomib include tiredness, nausea, diarrhoea, numbness or tingling in the hands and feet (peripheral neuropathy) and a tendency to bruise or bleed more easily (caused by a low platelet count).

The National Institute for Health and Clinical Excellence (NICE) is an independent body that was set up by the government. NICE assesses medicines and treatments and gives guidance to doctors on how they should be used in the NHS in England and Wales. The equivalent body in Scotland is the Scottish Medicines Consortium (SMC).

NICE has approved the use of bortezomib for people when:

• the myeloma has come back and
• they have had one only one previous course of treatment and
• they have either had or are unsuitable for a bone marrow transplant.

The SMC approved the use of bortezomib in Scotland for people:

• who have had at least two different courses of treatment and
• the myeloma is getting worse and
• no other treatment is working.

Other drugs, known as immunomodulatory drugs (IMiDs™) that work in a similar way to thalidomide are currently being developed. The drug lenalidomide (Revlimid®) has been shown to help to control myeloma. It is licensed to be used with the steroid dexamethasone, for people who have already had at least one course of treatment. Lenalidomide is a capsule taken once a day for three weeks, followed by a week off.

The main side effects of lenalidomide are being more at risk of infection (due to having a lowered white blood cell count), anaemia, possible bruising or bleeding (due to low platelet count), and rarely, constipation, a rash and sleepiness. When taken with dexamethasone, there is an increased risk of blood clots in the legs. You may be given blood thinning machines to reduce this risk.

Lenalidomide has not yet been assessed by NICE or the SMC.