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Multiple Myeloma - Overview

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2014

ON THIS PAGE: You will find some basic information about this disease and the parts of the body it may affect. This is the first page of Cancer.Net’s Guide to Multiple Myeloma. To see other pages, use the menu on the side of your screen. Think of that menu as a roadmap to this full guide.

Myeloma is a cancer of the plasma cells in the bone marrow, the spongy tissue inside of bones. Myeloma begins when normal plasma cells change and grow uncontrollably. Plasma cells are a part of the body's immune system and produce antibodies that help the body fight infection. Abnormal plasma cells can crowd out or suppress the growth of other cells in the bone marrow that produce red blood cells, white blood cells, and platelets. This suppression may result in anemia (from a shortage of red blood cells), excessive bleeding from cuts (from a shortage of platelets), and a decreased ability to fight infection (from a shortage of white blood cells and the body’s inability to respond to infection normally). 

Like regular plasma cells, myeloma cells can produce antibodies. However, myeloma cells are unable to produce normal, functioning antibodies. Instead, they make what is called “monoclonal protein,” or “M protein,” which can accumulate in the blood and urine, potentially causing damage to the kidneys and other organs. A person who has slightly too much of this “M protein” is said to have monoclonal gammopathy of unknown significance (MGUS).

Myeloma often causes structural bone damage resulting in painful fractures or bone breaks. Myeloma is usually called multiple myeloma because most people (90%) have multiple bone lesions at the time it is diagnosed. Solitary plasmacytoma is a mass of myeloma cells that involve only one site in the bone or other organs, most commonly in the upper respiratory tract, including the nose and throat. Extramedullary plasmacytoma describes myeloma that started outside the bone marrow in locations such as the lymph glands, sinuses, throat, liver, or under the skin.

Looking for More of an Overview?

If you would like additional introductory information, explore these related items. Please note these links will take you to other sections on Cancer.Net:

  • ASCO Answers Fact Sheet: Read a one-page fact sheet (available as a PDF) that offers an easy-to-print introduction to this type of cancer.
  • Cancer.Net Patient Education Video: View a short video led by an ASCO expert in this type of cancer that provides basic information and areas of research.

To continue reading this guide, use the menu on the side of your screen to select another section.  

Multiple Myeloma - Statistics

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2014

ON THIS PAGE: You will find information about how many people learn they have this type of cancer each year and some general survival information. Remember, survival rates depend on several factors. To see other pages, use the menu on the side of your screen.

This year, an estimated 24,050 adults (13,500 men and 10,550 women) in the United States will be diagnosed with multiple myeloma. It is estimated that 11,090 deaths (6,110 men and 4,980 women) from this disease will occur this year.

The five-year survival rate is the percentage of people who survive at least five years after the cancer is detected, excluding those who die from other diseases. The five-year survival rate of people with multiple myeloma is about 45%. However, several factors affect an individual’s survival, such as the person’s age and overall health. For instance, it is known that survival rates are higher in younger people than in older people. That is why cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of people with this type of cancer, but the actual risk for a particular individual may differ. It is not possible to tell a person how long he or she will live with multiple myeloma. Because the survival statistics are measured in five-year intervals, they may not represent advances made in the treatment or diagnosis of this cancer. This is particularly true for myeloma because major improvements in treatment have occurred during the past decade. Learn more about understanding statistics.

Statistics adapted from the American Cancer Society's publication, Cancer Facts and Figures 2014.

To continue reading this guide, use the menu on the side of your screen to select another section.

Multiple Myeloma - Risk Factors

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2014

ON THIS PAGE: You will find out more about the factors that increase the chance of developing this type of cancer. To see other pages, use the menu on the side of your screen.

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

The causes of myeloma are not known or well understood, and there are currently no known ways to prevent it. There are also no strong risk factors for myeloma. Mutations or changes in plasma cells are acquired, not inherited, so having a relative with the disease usually does not mean another family member is at higher risk for developing it. There appears to be a very slight increase in the incidence of the disease in first-degree relatives (parents or siblings) of people with multiple myeloma.

The following factors can raise a person's risk of developing myeloma:

Age. Myeloma occurs most commonly in people over 60. The average age at diagnosis is 70. Only 2% of cases occur in people under 40.

Race. Myeloma occurs twice as frequently in black people than in white people for unclear reasons.

Exposure to radiation or chemicals. People who have been exposed to radiation or to asbestos, benzene, pesticides, and other chemicals used in rubber manufacturing may be at higher risk for developing myeloma.

Personal history. People with a history of a solitary plasmacytoma of the bone are at greater risk for developing multiple myeloma.

Monoclonal gammopathy of unknown significance (MGUS). A person with a slight excess of one kind of antibody protein in his or her blood, called 'monoclonal protein' or 'M protein', has 1% chance of developing myeloma or another blood-related cancer called Waldenstrom’s macroglobulinemia per year (see the Stages section for more information).

Gender. Myeloma is slightly more common in men.

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Multiple Myeloma - Symptoms and Signs

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2014

ON THIS PAGE: You will find out more about body changes and other things that can signal a problem that may need medical care. To see other pages, use the menu on the side of your screen.

People with multiple myeloma may experience the following symptoms and signs. Sometimes, people with multiple myeloma do not show any of these symptoms. For people with myeloma who have no symptoms, their cancer may be discovered by a blood or urine test performed for some other reason, such as at an annual physical. Or, these symptoms may be caused by a medical condition that is not cancer.

  • Anemia is a low level of red blood cells, which happens when myeloma plasma cells suppress or crowd out healthy red blood cells.
  • Fatigue is usually caused by anemia and occurs in most people with myeloma.
  • Bone pain is a common symptom. Myeloma cells grow in the bone marrow, the spongy tissue inside of the bone, and cause local bone damage or generalized thinning of the bone, called osteoporosis. This makes the bone more likely to break. The back or ribs are the most common sites of bone pain, but any bone can be affected. Pain is usually worse with movement and at night. If cancer is in the spine, the vertebrae (individual bones that make up the spine) can collapse, which is known as a compression fracture. In advanced multiple myeloma, a patient may lose inches from his or her height due to compressed vertebrae.
  • Pain, numbness and weakness can happen sometime when collapse of the vertebra pushes against the spinal cord or pinches a nerve root coming out of the spine.
  • Kidney damage or failure: The "M protein" produced by the myeloma cells can clog up the kidney filter and cause kidney damage or failure
  • Weight lossnausea, thirst, muscle weakness, and mental confusion symptoms are related to kidney failure, hypercalcemia (high calcium levels in the blood), or other imbalances in blood chemicals.
  • Hypercalcemia, resulting in symptoms of drowsiness, constipation, and kidney damage. Hypercalcemia is a high level of calcium in the blood that can occur as a result of bone breakdown.
  • Fever and Infections, especially of the upper respiratory tract and lungs. Patients with myeloma have lower immunity, making it harder to fight infection.
  • Blood clots, nosebleeds, bleeding gums, bruising, and hazy vision caused by hyperviscosity, which is thickened blood, or low platelets.

If you are concerned about one or more of the symptoms or signs on this list, please talk with your doctor. Your doctor will ask how long and how often you’ve been experiencing the symptom(s), in addition to other questions. This is to help find out the cause of the problem, called a diagnosis.

If cancer is diagnosed, relieving symptoms remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.

The next section helps explain what tests and scans may be needed to learn more about the cause of the symptoms. Use the menu on the side of your screen to select Diagnosis, or you can select another section, to continue reading this guide.

Multiple Myeloma - Diagnosis

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2014

ON THIS PAGE: You will find a list of the common tests, procedures, and scans that doctors can use to find out what’s wrong and identify the cause of the problem. To see other pages, use the menu on the side of your screen.

Doctors use many tests to diagnose cancer and find out if it has spread to another part of the body, called metastasis. Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has spread. This list describes options for diagnosing this type of cancer, and not all tests listed will be used for every person. Your doctor may consider these factors when choosing a diagnostic test:

  • Age and medical condition
  • Type of cancer suspected
  • Signs and symptoms
  • Previous test results

The following tests may be used to diagnose multiple myeloma:

Blood and urine tests. Myeloma cells often secrete the antibody monoclonal immunoglobulin known as “M protein”. Levels of “M protein” in a patient's blood and urine are used to determine the extent of the disease and to monitor the effectiveness of treatment. In some patients, the myeloma cells only secrete part of the antibody, which is called the light chain.

Serum protein electrophoresis (SPE) or urine protein electrophoresis (UPE) helps identify and quantify "M protein" in the blood or urine. These tests help to see if the treatment is working and whether the disease is progressing or coming back.

Quantitative Immunoglobulin levels in blood help to quantify the amount of antibody levels in the blood: immunoglobulin G (IgG), immunoglobulin A (IgA) and immunoglobulin M (IgM). In multiple myeloma, when cancer protein is up, the normal antibody levels are down.

Free light chains can be quantified in the blood before the filtering action of the kidneys. This test is called a serum free light chain assay. This is a more sensitive test than measuring urine M spike, also known as Bence Jones protein, in the urine.

The levels of serum albumin and serum beta 2-microglobulin are measured using blood tests. Serum albumin is a blood protein made by the liver that is necessary for maintaining proper blood volume. (Serum beta 2-microglobulin, or β2-M, is a small protein that plays a role in immunologic defense.) These results are important for determining the stage of the cancer. Blood tests are also used to measure kidney function, calcium levels, and blood cell counts for possible anemia.

X-ray. An x-ray is a way to create a picture of the structures inside of your body using a small amount of radiation. X-rays are typically the first step in evaluating bones when myeloma is suspected or diagnosed.

Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. An MRI can show replacement of normal bone marrow by myeloma cells or plasmacytoma (a plasma cell tumor growing in bone or soft tissue), especially in the skull, spine, and pelvis. The detailed images may also show compression fractures of the spine or a tumor pressing on nerve roots. MRI can also be used to measure the tumor’s size.

Computed tomography (CT or CAT) scan. A CT scan creates a detailed, cross-sectional view that shows any abnormalities or tumors in soft tissues. A computer then combines these images into a three-dimensional picture of the inside of the body. In general, intravenous contrast dye often used for CT scans is avoided in patients with multiple myeloma. Please tell the radiologist or the radiology technician about your diagnosis before receiving dye injection into your vein.

Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive sugar substance is injected into the patient’s body. This sugar substance is taken up by cells that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body.

Integrated PET-CT scan. An integrated PET-CT scan combines the images from a positron emission tomography (PET) scan and a computed tomography (CT) scan, performed at the same time on the same machine. Together, the two scans create a more complete image than either test can offer alone.

Bone marrow aspiration and biopsy. These two procedures are similar and often done at the same time to examine the bone marrow. Bone marrow has both a solid and a liquid part. A bone marrow aspiration removes a sample of the fluid with a needle. A bone marrow biopsy is the removal of a small amount of solid tissue using a needle, and it is important to making a diagnosis of myeloma. The sample(s) are then analyzed by a pathologist, a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease. A common site for a bone marrow aspiration and biopsy is the pelvic bone, which is located in the lower back by the hip. The skin in that area is numbed with medication beforehand, and other types of anesthesia (medication to block the awareness of pain) may be used. 

Fat pad aspirate. If certain “M proteins” that are misfolded in a particular way are deposited in body tissues, it can cause organ dysfunction. This condition is called amyloidosis. If amyloidosis is a consideration, it may be necessary to take a sample of the abdominal fat pad (the collection of fat around a person's abdomen) for examination under a microscope, called a biopsy.

Molecular testing of the tumor. Your doctor may recommend running laboratory tests on a tumor sample to identify specific genes, proteins, and other factors unique to the tumor. Results of these tests may help guide your treatment options (see the Treatment Options section more details).

After diagnostic tests are done, your doctor will review all of the results with you. If the diagnosis is cancer, these results also help the doctor describe the cancer; this is called staging.

The next section helps explain the different stages for this type of cancer. Use the menu on the side of your screen to select Stages, or you can select another section, to continue reading this guide.  

Multiple Myeloma - Stages

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2014

ON THIS PAGE: You will learn about how doctors describe a cancer’s growth or spread. This is called the stage. To see other pages, use the menu on the side of your screen.

Staging is a way of describing where a cancer is located, if or where it has spread, and whether it is affecting other parts of the body. Doctors use diagnostic tests to find out the cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor decide what kind of treatment is best and can help predict a patient's prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.

For myeloma, it is important to begin with whether the patient is experiencing symptoms. It is common to classify patients with newly diagnosed myeloma as being either symptomatic from the disease (having symptoms and signs) or asymptomatic (without any symptoms). Patients without symptoms are generally watched closely without treatment, which is called active surveillance (see the Treatment Options section). Patients with symptoms or about to develop symptoms need treatment.

As described below, the symptoms related to myeloma include hypercalcemia (elevated blood Calcium), poor Renal or kidney function, Anemia, or Bone pain or bone lesions (CRAB).

  • Calcium levels increased: serum calcium > 0.25 mmol/L above the upper limit of normal or > 2.75 mmol/L
  • Renal insufficiency: creatinine > 173 mmol/L
  • Anemia hemoglobin 2 g/dl below the lower limit of normal or hemoglobin < 10 g/dL
  • Bone lesions: lytic lesions (areas of bone damage), osteoporosis (thinning of the bones), or a compression fracture of the spine (an MRI or CT test may clarify)
  • Other: symptomatic hyperviscosity, amyloidosis, and/or recurrent bacterial infections (more than two episodes in 12 months)

Durie-Salmon System

The Durie-Salmon system has traditionally been used for the staging of myeloma. This staging system is good for assessing the extent of the disease or size of the tumor. According to this system, there are three stages, stages I, II or III (1, 2 or 3). Each stage is further subclassified into A or B depending on whether kidney function has been affected, with the subclassification B meaning there is significant kidney damage.

Stage I: Many patients with stage I myeloma show no symptoms because there are fewer cancer cells in the body. If the cancer has affected kidney function, the prognosis may be worse regardless of the stage. Factors characteristic of stage I include:

  • Number of red blood cells within or slightly below normal range
  • Normal amount of calcium in the blood
  • Low levels of M protein in the blood or urine
    •   M protein <5 g/dL for IgG; <3 g/dL for IgA; <4g/24h for urinary light chain
    • No bone damage on x-rays

Stage II: More cancer cells are present in the body in stage II. Again, if kidney function is affected, then the prognosis worsens regardless of the stage. Criteria for stage II are defined as those that fit neither stage I nor stage III.

Stage III: Many cancer cells are present in the body at stage III. Factors characteristic of this stage are:

  • Anemia with a hemoglobin less than 8.5 gm/dL
  • Hypercalcemia
  • Advanced bone damage (more than three bone lesions)
  • High levels of M protein in the blood or urine, which is defined as:
    • M protein >7 g/dL for IgG; >5 g/dL for IgA; >12 g/24h for urinary light chain

International Staging System

Another classification system called the International Staging System (ISS) is now used more commonly. It defines the factors that influence patient survival. The ISS is based on data collected from patients with multiple myeloma from around the world. The system has three stages based on the measurement of serum albumin and the levels of serum β2 microglobulin. Recent efforts involve further classifying myeloma based upon patterns of gene expression in myeloma cells; this is an ongoing area of research.

Stage I: β2-M less than 3.5 mg/L and albumin greater than or equal to 3.5 gm/dL.

Stage II: Either β2-M greater than 3.5 mg/L but not greater than 5.5 mg/dL and/or albumin less than 3.5 g/dL.

Stage III: β2-M greater than 5.5 mg/L.

Recurrent or relapsed myeloma. Myeloma that returns after a period of being in control after treatment is called recurrent myeloma or relapsed myeloma. If there is a recurrence, the cancer may need to be staged again (called re-staging) using one of  the systems above.

Other classifications

Some people have no symptoms of myeloma, but they may have abnormal plasma cells producing an abnormal protein (M protein). Doctors generally monitor these people closely, and active treatment does not begin unless this condition turns into symptomatic myeloma.

Monoclonal gammopathy of unknown significance (MGUS). This condition occurs when people have a low level of M protein (meaning there are small quantities of abnormal plasma cells), but they do not have any other evidence of myeloma, such as bone damage, excessive plasma cells, or low numbers of red blood cells. People with MGUS have a 1% chance per year of developing myeloma or rarely other types of blood problems such as chronic lymphocytic leukemia (CLL), lymphoma, Waldenstrom's macroglobulinemia, or amyloidosis. For this reason, a person with MGUS should be monitored for health changes by his or her doctor on a regular basis.

Smoldering multiple myeloma (SMM) or asymptomatic myeloma. People who are diagnosed with SMM have slightly higher levels of M protein and more plasma cells in the bone marrow than people with MGUS. There is still no evidence of symptoms or signs of myeloma, such as bone disease or anemia. But, a person with SMM may be prescribed bisphosphonates for symptoms of osteoporosis or osteopenia (a low density of bone minerals). Most people with SMM eventually develop myeloma. For this reason, the health of people with smoldering myeloma should be closely monitored by their doctors who may recommend starting treatment when there is progression of disease and patients are at the risk of developing symptoms within 18 months to two years.

Prognosis

The International Staging System (ISS) of myeloma gives information about prognosis and predicts the person’s chance of recovery. Researchers are also looking at other ways to predict prognosis for patients with multiple myeloma. Some of these ways of evaluating prognosis include:

  • High levels of β2-M may indicate a large number of myeloma cells are present and kidney damage has occurred. The level of this protein increases as myeloma becomes more advanced.
  • Lower amounts of serum albumin may indicate a poorer prognosis.
  • Lactase dehydrogenase (LDH) is an enzyme; higher blood levels of LDH indicate a poorer prognosis.
  • Abnormalities of chromosomes in the cancer cells may show how aggressive the cancer is.
  • A plasma cell labeling index can be done in a specialized laboratory using bone marrow samples to find out how fast the cancer cells are growing.

Learn more about talking with the doctor about prognosis.

Information about the cancer’s stage will help the doctor recommend a treatment plan.  The next section helps explain the treatment options for this type of cancer. Use the menu on the side of your screen to select Treatment Options, or you can select another section, to continue reading this guide.  

Multiple Myeloma - Treatment

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2014

ON THIS PAGE: You will learn about the different ways doctors use to treat people with this type of cancer. To see other pages, use the menu on the side of your screen.

This section outlines treatments that are the standard of care (the best proven treatments available) for this specific type of cancer. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new approach to treatment to evaluate whether it is safe, effective, and possibly better than the standard treatment. Clinical trials may test such approaches as a new drug, a new combination of standard treatments, or new doses of current therapies. Research for new myeloma treatments is very active, and many clinical trials are offered. Your doctor can help you review all treatment options. For more information, see the Clinical Trials and Latest Research sections.

Treatment overview

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team.

The treatment of multiple myeloma depends on whether the patient is experiencing symptoms (see the Stages section) and the patient’s overall health. In many cases, a team of doctors will work with the patient to determine the best treatment plan. The goals of treatment are to eliminate myeloma cells, control tumor growth, control pain, and allow patients to have an active life.

While there is no cure for multiple myeloma, the cancer can be managed successfully in many patients for years. Doctors help patients manage the symptoms of myeloma so patients can lead an active life.

Descriptions of the most common treatment options for multiple myeloma are listed below; they are divided into treatment options for people without symptoms and for people with symptoms. In addition, treatment options may depend on whether the patient is newly diagnosed with myeloma or is experiencing a recurrence of the disease. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care. Take time to learn about all of your treatment options, including clinical trials, and be sure to ask questions about things that are unclear. Also, talk about the goals of each treatment with your doctor and what you can expect while receiving the treatment. Learn more about making treatment decisions.

Active surveillance for patients without symptoms

Patients with early-stage myeloma and no symptoms, called smoldering myeloma (SMM), may simply be closely monitored. This approach is called active surveillance or watchful waiting. If symptoms appear, then active treatment starts. Currently, clinical trials are being done to identify and treat patients with “high-risk” SMM, which means those who are at risk of developing symptoms within 18 months to two years. 

Overview of treatment options for patients with symptoms

Treatment for patients with symptomatic myeloma includes both treatment for the disease as well as supportive therapy to improve a patient’s quality of life, such as by relieving symptoms and maintaining good nutrition. Disease-directed treatment typically includes drug therapy, such as targeted therapy or chemotherapy, with or without steroids. Stem cell transplantation may be an option. Other types of treatments, such as radiation therapy and surgery, are used in specific circumstances. Each type of treatment is described below.

The treatment plan includes different phases of treatment. Induction therapy for rapid control of cancer and help relieve symptoms, followed by

  • consolidation with more chemotherapy or
  • stem cell transplant and maintenance therapy over a prolonged period of time to prevent recurrence of cancer.

Targeted therapies

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells. Targeted therapy has proven in recent years to be quite successful at controlling myeloma, and researchers continue to investigate new and evolving drugs for this disease in clinical trials.

Lenalidomide (Revlimid), pomalidomide (Pomalyst), and thalidomide (Synovir, Thalomid) are drugs that stop the growth of myeloma cells in the bone marrow. These drugs strengthen the immune cells to attack cancer cells. They starve the cancer cells by blocking new blood vessel formation, a process called angiogenesis.

Bortezomib (Velcade) and carfilzomib (Kyprolis) are classified as proteasome inhibitors, and they target specific enzymes called proteasomes that digest proteins in the cells. Because myeloma cells produce a lot of proteins (see the Overview), they are particularly vulnerable to this type of drug.

Thalidomide, lenalidomide, and bortezomib may be used to treat newly diagnosed patients, while lenalidomide, bortezomib, pomalidomide, and carfilzomib are effective for treating recurrent myeloma. Targeted therapies may also be used in combination with chemotherapy or steroid medications (see below), as certain combinations of drugs can sometimes have a better effect than a single drug. For example, the drugs lenalidomide, bortezomib, and dexamethasone, as well as bortezomib, cyclophosphamide, and dexamethasone, are offered in combination. Clinical trials are underway to explore whether the combination of lenalidomide, bortezomib, and dexamethasone alone may be as effective as lenalidomide, bortezomib, and dexamethansone followed by stem cell transplant (see below). Also, targeted therapy can be effectively used before or after a stem cell transplant. However, the decision to undergo a stem cell/bone marrow transplant is complex and should be discussed carefully with your doctor.

Research has shown that maintenance therapy (the ongoing use of a drug) with lenalidomide extends patients’ survival time and extends the time they live without active myeloma. However, maintenance therapy has to be used with caution. Find out more about maintenance therapy.

Recent studies show that not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify genes, proteins, and other factors. As a result, doctors can better match each patient with the most effective treatment whenever possible. In addition, many research studies are taking place now to find out more about specific molecular targets and new treatments directed at them. Talk with your doctor about possible side effects for a specific medication and how they can be managed. Learn more about targeted treatments.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication, or a hematologist, a doctor who specializes in treating blood disorders.

Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally). A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time.

Chemotherapy drugs that have been used successfully for the treatment of myeloma includes cyclophosphamide (Cytoxan, Neosar), doxorubicin (Adriamycin, Doxil), melphalan (Alkeran), etoposide (Toposar, VePesid), cisplatin (Platinol), and carmustine (BiCNU).

Often, more than one drug is used at a time. It may also be recommended to combine chemotherapy with other types of treatment, including targeted therapies (see above) or steroids (see below). For instance, the combination of melphalan, the steroid prednisone, and a targeted therapy called bortezomib is approved by the U.S. Food and Drug Administration (FDA) for the initial treatment of multiple myeloma because it increases survival when compared with melphalan and prednisone. A patient may also be given a combination of melphalan, prednisone, and thalidomide. Additional combinations of drugs are being evaluated in clinical trials. 

The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhea or constipation. Other side effects include peripheral neuropathy (tingling or numbness in feet or hands), blood clotting problems, and low blood counts. These side effects usually go away once treatment is finished. Occasionally an allergic reaction such as skin rash or urticaria may occur and the drug may have to be stopped.

The length of chemotherapy treatment varies from patient to patient and is usually given until the myeloma is well-controlled.

Learn more about chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases.

Other drug therapy

Steroids, such as prednisone and dexamethasone (multiple brand names), may be given alone or at the same time as other drug therapy, such as targeted therapy or chemotherapy (see above).

In addition, most patients with myeloma receive monthly infusions of bisphosphonate therapy, which are drugs that help to prevent bone disease from myeloma. Learn more about bisphosphonate therapy.

Stem cell transplantation/bone marrow transplantation

A stem cell transplant is a medical procedure in which bone marrow that contains cancer is replaced by highly specialized cells, called hematopoietic stem cells, that develop into healthy red blood cells, white blood cells, and platelets in the bone marrow. Hematopoietic stem cells are blood-forming cells found both in the bloodstream and in the bone marrow. Today, this procedure is more commonly called a stem cell transplant, rather than bone marrow transplant, because it is the stem cells in the blood that are typically being transplanted, not the actual bone marrow tissue.

Before recommending transplantation, doctors will talk with the patient about the risks of this treatment and consider several other factors, such as the type of cancer, results of any previous treatment, and the patient’s age and general health.

There are two types of stem cell transplantation depending on the source of the replacement blood stem cells: allogeneic (ALLO) and autologous (AUTO). ALLO uses donated stem cells, while AUTO uses the patient’s own stem cells. For multiple myeloma, AUTO is more commonly used. ALLO is being studied in clinical trials.

In both types, the goal is to destroy all of the cancer cells in the marrow, blood, and other parts of the body using high doses of chemotherapy and/or radiation therapy and then allow replacement blood stem cells to create healthy bone marrow. Learn more about stem cell and bone marrow transplantation.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time.

Doctors may recommend radiation therapy for patients with bone pain when chemotherapy is not effective or as a way to control pain. However, the use of radiation therapy should be a careful decision. In many instances, pain (especially back pain) is due to structural damage to the bone. Radiation therapy will not help this type of pain and may compromise the bone marrow's response to future treatment.

Side effects of radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished. Learn more about radiation therapy.

Surgery

Surgery is not a disease-directed treatment option for multiple myeloma, but it may be used to relieve symptoms (see below).

Getting care for symptoms and side effects

Cancer and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care can help a person at any stage of illness. People often receive treatment for the cancer and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, and other therapies. For people with myeloma, supportive care to reduce symptoms and complications may include:

  • Antibiotics and intravenous immunoglobulins (a blood product given through an IV) may treat or prevent infections.
  • Analgesics, or pain medications, are given to those patients who need help managing bone pain. They can include a wide range of drugs from acetominophen (Tylenol) to opiates. Non-steroidal anti inflammatory drugs (NSAID) should be avoided.
  • Antiviral medications may treat or prevent viral infections such as herpes zoster, particularly for those patients who are being treated with a proteasome inhibitor.
  • A blood thinner will help prevent blood clots for those patients who are being treated with a combination of an immunomodulatory agent such as thalidomide (Thalomid) or lenalidomide (Revlimid), or pomalidomide (Pomalyst) and dexamethasone, which is a steroid.
  • Antidepressants are frequently prescribed not only to help patients cope with the normal reaction to a cancer diagnosis, but sometimes to treat painful neuropathy that can be caused by the myeloma itself or by treatments for myeloma. Other drugs may also be prescribed to help with painful neuropathy.
  • Antacids or proton pump inhibitors are frequently given to patients who are taking steroids to prevent or treat gastrointestinal problems.
  • Plasmapheresis is used to reduce the thickness of the blood and relieve the related symptoms. During this procedure, blood is taken from a vein and plasma (the liquid part of the blood) is removed from the body after it is separated from the red and white blood cells. The blood cells are then mixed with a plasma substitute, usually an albumin solution, and returned to the patient. This procedure is often done continuously using a blood cell separator.
  • As mentioned above, bisphosphonates are drugs that increase bone density. They are given to help with bone pain and reduce the risk of fractures. These drugs also prevent high levels of calcium in the blood, which reduces the effects of having too much calcium circulating in the blood.
  • Exercise is recommended to maintain bone strength, reduce the loss of calcium, and help prevent fatigue.
  • Drinking an adequate amount of water and other healthy fluids can flush the kidneys and help them filter impurities from the blood.
  • A balanced diet high in calories and protein helps prevent fatigue and infection, as does getting plenty of rest and reducing stress.

You may also receive palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy, surgery, or radiation therapy. For example, surgery may be used to relieve pressure from a plasmacytoma on the spine or other organs. More recently, procedures have been considered to relieve pain, restore lost height due to collapsing vertebra, and strengthen the spine. Procedures include kyphoplasty, which inflates a balloon between vertebrae to clear the space, then removing the balloon and injecting bone cement to stabilize the spine. Another procedure is a vertebroplasty, which means injecting bone cement to stabilize fractures in the spine. Talk with your doctor about the goals of each treatment in your treatment plan.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and supportive care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem so it is addressed as quickly as possible. Learn more about palliative care

Refractory myeloma

The disease is called refractory myeloma if the cancer no longer responds to treatment. Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer because there can be different opinions about the best treatment plan. Learn more about seeking a second opinion before starting treatment, so you are comfortable with the treatment plan chosen. This discussion may include clinical trials.

For people with refractory myeloma, supportive care to reduce symptoms and complications is also very important.

Remission and the chance of recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. A remission can be temporary or permanent. This uncertainty leads to many survivors feeling worried or anxious that the cancer will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the cancer returning. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.

If the cancer does return after the original treatment, it is called recurrent myeloma or relapsed myeloma. When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the therapies described above such as targeted therapy and chemotherapy, but they may be used in a different combination or given at a different pace.

Your doctor may also suggest clinical trials that are studying new ways to treat recurrent/relapsed myeloma. There are several drugs currently being researched in the late stages of clinical trials that have shown promise as treatments for recurrent myeloma, such as the monoclonal antibodies elotuzumab, SAR650984, and daratumumab. See the Latest Research section for more information.

People with relapsed myeloma often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. Learn more about dealing with cancer recurrence.

For most patients, a diagnosis of refractory cancer is very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

If treatment fails

Recovery from cancer is not always possible. If treatment is not successful, the disease may be called advanced or terminal cancer.

This diagnosis is stressful, and this is difficult to discuss for many people. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.

Patients who have advanced cancer and who are expected to live less than six months may want to consider a type of palliative care called hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families. Learn more about advanced cancer care planning.

After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.

The next section helps explain clinical trials, which are research studies. Use the menu on the side of your screen to select About Clinical Trials, or you can select another section, to continue reading this guide.  

Multiple Myeloma - About Clinical Trials

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2014

ON THIS PAGE: You will learn more about clinical trials, which are the main way that new medical approaches are tested to see how well they work. To see other pages, use the menu on the side of your screen.

Doctors and scientists are always looking for better ways to treat patients with multiple myeloma. To make scientific advances, doctors create research studies involving volunteers, called clinical trials.

Many clinical trials are focused on new treatments, evaluating whether a new treatment is safe, effective, and possibly better than the current (standard) treatment. These types of studies evaluate new drugs, different combinations of existing treatments, new approaches to radiation therapy or surgery, and new methods of treatment. This is a very active area of research for myeloma. Patients who participate in clinical trials are often among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.

There are also clinical trials that study new ways to ease symptoms and side effects during treatment and manage the late effects that may occur after treatment. Talk with your doctor about clinical trials regarding side effects. In addition, there are ongoing studies for patients with smoldering or inactive myeloma to try to prevent it progressing to active disease.

Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that these studies are the only way to make progress in treating multiple myeloma. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with multiple myeloma.

Sometimes people have concerns that, by participating in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” The use of placebos in cancer clinical trials is rare, and is only done when comparing a standard therapy plus a placebo with a standard therapy plus a new drug. This means all patients are receiving treatment. When a placebo is used in a study, it is done with the full knowledge of the participants. Find out more about placebos in cancer clinical trials.

To join a clinical trial, patients must participate in a process known as informed consent. During informed consent, the doctor should list all of the patient’s options so that the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different from the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment.

For specific topics being studied for multiple myeloma, learn more in the Latest Research section.

Patients who participate in a clinical trial may stop participating at any time for any personal or medical reason. This may include that the new treatment is not working or there are serious side effects. Clinical trials are also closely monitored by experts who watch for any problems with each study. It is important that patients participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trial ends, and/or if the patient chooses to leave the clinical trial before it ends. 

Cancer.Net offers a lot of information about cancer clinical trials in other areas of the website, including a complete section on clinical trials and places to search for clinical trials for a specific type of cancer.

The next section helps explain the areas of research going on today about this type of cancer. Use the menu on the side of your screen to select Latest Research, or you can select another section, to continue reading this guide.  

Multiple Myeloma - Latest Research

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2014

ON THIS PAGE: You will read about the scientific research being done now to learn more about this type of cancer and how to treat it. To see other pages, use the menu on the side of your screen.

Doctors are working to learn more about myeloma, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options best for you. Below are some of the areas researchers are looking into. With the fast pace of myeloma research, patients are encouraged to ask about clinical trials open to them.

Expanded use of stem cell transplantation. While autologous (AUTO) stem cell transplantation is a standard treatment for myeloma, researchers are studying the benefits of tandem (double) AUTO transplantations, ALLO transplantations, and tandem AUTO mini-allogeneic transplantations. Autologous means the stem cells are from the patient, and allogeneic means that the stem cells came from a donor. For more information about transplantation, read the Treatment Options section.

New drugs. Rapid progress is being made in researching new treatments of myeloma. A variety of new drugs are being studied for the treatment of myeloma, including the following:

  • A monoclonal antibody is a substance made in a laboratory that acts like the antibodies the body’s immune system naturally makes to fight diseases such as a tumor. Many of these drugs are being studied for multiple myeloma, such as elotuzumab. Clinical trials using elotuzumab, usually in combination with lenalidomide and dexamethasone, SAR650984, and daratumumab are underway. Arry520 antiCD138 monoclonal antibody-immunoconjugate is being studied at this time as well. Elotuzumab, SAR650984, and daratumumab have all received breakthrough designation from the FDA, which means they are on a faster-track review.
  • Histone deacetylase (HDAC) inhibitors are an area of active research for their use as a treatment option for myeloma, both as single drugs and in combination with other drug therapy. Drugs in this category include panobinostat and ACY1215. Panobinostat has completed phase III of clinical trials and is now waiting for FDA approval. Lenalidomide and dexamethasone with or without elotuzumab and lenalidomide and dexamethasone with or without ixazomib are both finished phase III of clinical trials.
  • The fibroblast growth factor receptor 3 (FGFR3) is expressed in approximately 15% of patients with myeloma and is involved in cell growth, angiogenesis, and wound healing. Drugs that inhibit FGFR3 are being developed to help control cancer in these patients.
  • Three new proteasome inhibitors, called ixazomib (MLN9708), oprozomib, and marizomib (NPI-0052), are currently being researched in clinical trials.
  • Late-phase III studies to treat myeloma are also underway with drugs called masitinib and plitidepsin (Aplidin).

Myeloma represents a new treatment paradigm (a set of assumptions and practices) in cancer because the new drugs that target the tumor cell, tumor-bone marrow interaction, and bone marrow environment can overcome conventional drug resistance. Drugs are first tested in patients with advanced myeloma and then used to treat patients with earlier stage myeloma.

Drug combinations. Most myeloma cells will eventually become resistant to standard chemotherapy, a condition called multidrug resistance. New drugs and combinations of approved drugs are being researched to provide more options for patients with myeloma. Many new drug combinations are being studied, including:

  • Bortezomib and lenalidomide in combination with dexamethasone
  • Bortezomib, cyclophosphamide, and dexamethasone
  • Lenalidomide, carfilzomib, and dexamethasone
  • Carfilzomib, pomalidomide, and dexamethasone
  • Pomalidomide, dexamethasone, and clarithromycin (Biaxin)

Immunotherapy. This therapy, also called biologic therapy, helps to boost a person's immune system to fight cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function. Vaccines are a type of immunotherapy being explored in the treatment of multiple myeloma. Learn more about immunotherapy.

Cytogenetics. Cytogenetics, which is the study of genetic changes in cells, and molecular studies may be performed on the tissue sample removed during the biopsy to find out how aggressive the cancer is.

Supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current myeloma treatments in order to improve patients’ comfort and quality of life. For instance, research announced at a recent ASCO Annual Meeting: Anti-Depressant Helps Manage Peripheral Neuropathy From Chemotherapy.

Looking for More About the Latest Research?

If you would like additional information about the latest areas of research regarding myeloma, explore these related items that will take you outside of this guide:

The next section addresses how to cope with the symptoms of the disease or the side effects of its treatment. Use the menu on the side of your screen to select Coping with Side Effects, or you can select another section, to continue reading this guide.  

Multiple Myeloma - Coping with Side Effects

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2014

ON THIS PAGE: You will find out more about steps to take to help cope with physical, social, and emotional side effects. This page includes several links outside of this guide to other sections of this website. To see other pages, use the menu on the side of your screen.

Fear of treatment side effects is common after a diagnosis of cancer, but it may help to know that preventing and controlling side effects is a major focus of your health care team. This is called palliative or supportive care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

Common side effects from each treatment option for multiple myeloma are described in detail within the Treatment Options section. Learn more about the most common side effects of cancer and different treatments, along with ways to prevent or control them. Side effects depend on a variety of factors, including the cancer’s stage, the length and dosage of treatment(s), and your overall health.

Before treatment begins, talk with your doctor about possible side effects of each type of treatment you will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them. And, ask about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with multiple myeloma. Learn more about caregiving.

In addition to physical side effects, there may be emotional and social effects as well. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies, including concerns about managing the cost of your cancer care

During and after treatment, be sure to tell the health care team about the side effects you experience, even if you feel they are not serious. Sometimes, side effects can last beyond the treatment period, called a long-term side effect. A side effect that occurs months or years after treatment is called a late effect. Treatment of both types of effects is an important part of survivorship care. Learn more by reading the After Treatment section or talking with your doctor.

The next section helps explain medical tests and check-ups needed after the cancer is controlled. Use the menu on the side of your screen to select After Treatment, or you can select another section, to continue reading this guide.  

Multiple Myeloma - After Treatment

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2014

ON THIS PAGE: You will read about your medical care after cancer treatment is finished and why this follow-up care is important. To see other pages, use the menu on the side of your screen.

After active treatment for multiple myeloma ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests during the coming months and years.

After successful control of the cancer with treatment, people with myeloma should have regular check-ups to watch for any recurrence of cancer. Your doctor may recommend maintenance therapy to prevent recurrence of cancer. Most patients requiring treatment for systemic myeloma are also treated with intravenous monthly bisphosphonates; however, the development of kidney problems or osteonecrosis (a small area of dead bone) of the jaw in a small fraction of patients after long-term use may modify recommendations for bisphosphonate use in the future (see the Treatment Options section for more information).

ASCO offers cancer treatment summary forms to help keep track of the cancer treatment you received and develop a survivorship care plan once treatment is completed.

People recovering from multiple myeloma are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about the next steps to take in survivorship, including making positive lifestyle changes.

The next section offers a list of questions you may want to ask. Use the menu on the side of your screen to select Questions to Ask the Doctor, or you can select another section, to continue reading this guide.

Multiple Myeloma - Questions to Ask the Doctor

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2014

ON THIS PAGE: You will find some questions to ask your doctor or other members of your health care team, to help you better understand your diagnosis, treatment plan, and overall care. To see other pages, use the menu on the side of your screen.

Talking often with the doctor is important to make informed decisions about your health care. These suggested questions are a starting point to help you learn more about your cancer care and treatment. You are also encouraged to ask additional questions that are important to you. You may want to print this list and bring it to your next appointment, or download Cancer.Net’s free mobile app for an e-list and other interactive tools to manage your care.

  • Can you explain my pathology report (laboratory test results) to me?
  • What stage is the myeloma?
  • Am I symptomatic or asymptomatic? What does this mean?
  • Is my kidney function being affected?
  • Should I consider cytogenetic testing? What is involved, and what do the results mean?
  • What are my treatment options?
  • What clinical trials are open to me? Where are they located, and how do I find out more about them?
  • What treatment plan do you recommend? Why?
  • What is the goal of each treatment? Is it to eliminate the cancer, help me feel better, or both?
  • Who will be part of my health care team, and what does each member do?
  • Should I get a second opinion?
  • Who will be coordinating my overall treatment and follow-up care?
  • What are the possible side effects of this treatment, both in the short term and long term?
  • How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?
  • Could this treatment affect my sex life? If so, how and for how long?
  • Could this treatment affect my ability to become pregnant or have children? If so, should I talk with a fertility specialist before cancer treatment begins?
  • If I’m worried about managing the costs related to my medical care, who can help me with these concerns?
  • What follow-up tests will I need, and how often will I need them?
  • What support services are available to me? To my family?
  • Where can I get more information?
  • Whom should I call for questions or problems?

The next section offers some more resources that may be helpful to you. Use the menu on the side of your screen to select Additional Resources, or you can select another section, to continue reading this guide.  

Multiple Myeloma - Additional Resources

This section has been reviewed and approved by the Cancer.Net Editorial Board, 07/2014

ON THIS PAGE: You will find some helpful links to other areas of Cancer.Net that provide information about cancer care and treatment. This is the final page of Cancer.Net’s Guide to Multiple Myeloma. To go back and review other pages, use the menu on the side of your screen.

Cancer.Net includes many other sections about the medical and emotional aspects of cancer, both for the person diagnosed and their family members and friends. This website is meant to be a resource for you and your loved ones from the time of diagnosis, through treatment, and beyond. Here are a few sections that may get you started in exploring the rest of Cancer.Net:

This is the end of Cancer.Net’s Guide to Multiple Myeloma. Use the menu on the side of your screen to select another section to continue reading this guide.