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Multiple Myeloma - Introduction

This section has been reviewed and approved by the Cancer.Net Editorial Board, 10/2016

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. Think of that menu as a roadmap to this full guide.

Myeloma is a blood cancer of cells found in the bone marrow, specifically the so-called “plasma cells.” The bone marrow is the spongy tissue inside your bones that normally generates the components of your blood. Myeloma begins when healthy plasma cells change and grow out of control. Plasma cells are normally a key part of the body's immune system. In particular, they 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. They also reduce the creation of normal plasma cells, which lowers a person’s immunity. This suppression may result in:

  • Anemia, from a shortage of red blood cells

  • Excessive bleeding from cuts, from a shortage of platelets

  • Decreased ability to fight infection, from a shortage of white blood cells and the body’s inability to respond to infection because of the presence of abnormal antibodies

To help you understand this better, it is important to explain that like regular plasma cells, myeloma cells can produce antibodies. However, myeloma cells are unable to produce healthy, functioning antibodies. Instead, they make what is called “monoclonal protein,” or “M protein.” M protein can build up in the blood and urine, potentially damaging the kidneys and other organs, as well as reducing immunity. A healthy person who is found to have a small amount of this M protein is said to have monoclonal gammopathy of undetermined significance (MGUS).

Myeloma causes structural bone damage, which can result in weakened bones and leads to painful fractures or bone breaks over time. Myeloma is usually called multiple myeloma because most people (90% or more) have multiple bone lesions when diagnosed or lesions develop over the course of the illness.

Solitary plasmacytoma is a mass of myeloma cells that involves only 1 site in the bone or, less commonly, other organs, such as in the upper respiratory tract, including the nose and throat or gastrointestinal systems.

Extramedullary plasmacytoma describes myeloma that started outside the bone marrow in locations such as the lymph glands, sinuses, throat, liver, digestive tract, or under the skin.

Normal Bone Marrow

Normal Bone Marrow
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Multiple Myeloma Disease

Multiple Myeloma Disease
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These images used with permission by the College of American Pathologists.

Looking for More of an Introduction?

If you would like more of an introduction, explore these related items. Please note that these links will take you to other sections on Cancer.Net:

  • ASCO Answers Fact Sheet: Read a 1-page fact sheet that offers an introduction to this type of cancer. This fact sheet is available as a PDF, so it is easy to print out.

  • 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.

The next section in this guide is Statistics. It helps explain how many people are diagnosed with this disease and general survival rates. Or, use the menu to choose another section to continue reading this guide.  

Multiple Myeloma - Statistics

This section has been reviewed and approved by the Cancer.Net Editorial Board, 10/2016

ON THIS PAGE: You will find information about how many people are diagnosed with this type of cancer each year. You will also learn some general information on surviving the disease. Remember, survival rates depend on several factors. To see other pages, use the menu.

Multiple myeloma is not a common cancer but is the second most common blood cancer after non-Hodgkin lymphoma. In the United States, the lifetime risk for multiple myeloma is about 1 in 143. This year, an estimated 30,300 adults (17,900 men and 12,430 women) in the United States will be diagnosed with multiple myeloma.

It is estimated that 12,650 deaths (6,430 men and 6,220 women) from this disease will occur this year.

The 5-year survival rate tells you what percent of people live at least 5 years after the cancer is found. Percent means how many out of 100. The 5-year survival rate for people with multiple myeloma is about 47%. Survival has steadily increased over the last decade, so the 5-year survival rate may underestimate the impact of recent progress made in the treatment of this disease. Moreover, 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.

It is important to remember that statistics on how many people survive this type of cancer are an estimate. The estimate comes from data based on thousands of people with this cancer in the United States each year. So, your own risk may be different. Doctors cannot say for sure how long anyone will live with multiple myeloma. Also, experts measure the survival statistics every 5 years. This means that the estimate may not show the results of better diagnosis or treatment available for less than 5 years. Learn more about understanding statistics.

Statistics adapted from the American Cancer Society's publication, Cancer Facts and Figures 2016, and the National Cancer Institute Surveillance Epidemiology and End Results (SEER) database.

The next section in this guide is Medical Illustrations. It offers drawings of body parts often affected by this disease. Or, use the menu to choose another section to continue reading this guide.  

Multiple Myeloma - Medical Illustrations

This section has been reviewed and approved by the Cancer.Net Editorial Board, 10/2016

ON THIS PAGE: You will find basic drawings of the main body parts affected by this disease and images of what cells look like when affected by multiple myeloma. To see other pages, use the menu.

Normal Bone Marrow

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Multiple Myeloma Disease

Click to Enlarge

The next section in this guide is Risk Factors. It explains what factors may increase the chance of developing this disease. Or, use the menu to choose another section to continue reading this guide.  

Multiple Myeloma - Risk Factors

This section has been reviewed and approved by the Cancer.Net Editorial Board, 10/2016

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.

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. There are currently no known ways to prevent it. Currently, there are also no obvious 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 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. The reasons why are unclear, although it appears to also be more common in the Middle East, North Africa, and the Mediterranean.

  • 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. Those exposed to wood products, such as carpenters, furniture makers, and paper makers, are also at higher risk. There is also a high incidence of myeloma among professional firefighters and those exposed to herbicides, including Agent Orange.

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

  • Monoclonal gammopathy of undetermined significance (MGUS). As explained in the Introduction, a person with a small amount of M protein in his or her blood has a 1% to 2% chance of developing myeloma, lymphoma, 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.

The next section in this guide is Symptoms and Signs. It explains what body changes or medical problems this disease can cause. Or, use the menu to choose another section to continue reading this guide.

Multiple Myeloma - Symptoms and Signs

This section has been reviewed and approved by the Cancer.Net Editorial Board, 10/2016

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.

People with multiple myeloma may experience a number of different symptoms and signs. Sometimes, people with multiple myeloma do not have any of these changes. For people with myeloma who have no symptoms, their cancer may be discovered by a blood or urine test that is performed for a different reason, such as for an annual physical. Or, the cause of a symptom may be another medical condition that is not cancer.

  • Anemia is a low level of red blood cells. This happens when myeloma plasma cells suppress or crowd out healthy red blood cells.

  • Fatigue is usually caused by anemia or other factors associated with myeloma, such as abnormal cytokine production. It occurs in most people with myeloma.

  • Bone pain is a common symptom. Myeloma cells grow in the bone marrow and cortical bone, causing 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. The pain is usually worse when someone moves and at night. If cancer is in the spine, the vertebrae (the 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 over the course of their illness.

  • Pain, numbness, and weakness can sometimes happen when collapsed vertebrae press against the spinal cord or pinch a nerve coming out of the spine.

  • Excess M protein may lead to kidney damage or failure, an important issue to be aware of.

  • Hypercalcemia is a high level of calcium in the blood that can arise as a result of bone breakdown. It can cause drowsiness, constipation, and kidney damage.

  • Symptoms of weight loss, nausea, thirst, muscle weakness, and mental confusion are related to kidney failure, hypercalcemia, or other imbalances in blood chemicals.

  • Fever and infections, especially of the upper respiratory tract and lungs, may arise as a result of the lower immunity that people with myeloma have. This makes it harder to fight infection.

  • Blood clots, nosebleeds, bleeding gums, bruising, hazy vision caused by hyperviscosity, which is thickened blood, and low platelets are other symptoms of multiple myeloma.

If you are concerned about any changes you experience, 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 in this guide is Diagnosis. It explains what tests may be needed to learn more about the cause of the symptoms. Or, use the menu to choose another section to continue reading this guide.  

Multiple Myeloma - Diagnosis

This section has been reviewed and approved by the Cancer.Net Editorial Board, 10/2016

ON THIS PAGE: You will find a list of common tests, procedures, and scans that doctors use to find the cause of a medical problem. To see other pages, use the menu.

Doctors use many tests to find, or diagnose, cancer. They also do tests to learn if cancer has spread to another part of the body from where it started. If this happens, it is called metastasis. For example, imaging tests can show if the cancer has spread. Imaging tests show pictures of the inside of the body. Doctors may also do tests to learn which treatments could work best.

For most types of cancer, a biopsy is the only sure way for the doctor to know whether an area of the body has cancer. In a biopsy, the doctor takes a small sample of tissue for testing in a laboratory. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis.

This list describes options for diagnosing this type of cancer. Not all tests listed below will be used for every person. Your doctor may consider these factors when choosing a diagnostic test:

  • The type of cancer suspected

  • Your signs and symptoms

  • Your age and medical condition

  • The results of earlier medical tests

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. M protein levels 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.

    The amount of M protein in the blood or urine is measured by serum protein electrophoresis (SPE) or urine protein electrophoresis (UPE). These tests help to see if the treatment is working and whether the disease is progressing or coming back.

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

    The amount of free light chains in the blood can be measured before the blood is filtered by the kidneys. This test is called a serum free light chain assay. This is a more sensitive test than measuring M protein in the urine, but both are important to measure. When a light chain is found in the urine, it is called Bence Jones protein.

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

  • 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 taken as part of the doctor’s evaluation of the patient’s skeletal system 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 if normal bone marrow has been replaced by myeloma cells or by a plasmacytoma, especially in the skull, spine, and pelvis. A plasmacytoma is a plasma cell tumor growing in bone or soft tissue. 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 3-dimensional picture of the inside of the body. It is important to note that the intravenous contrast dye often used for CT scans for other types of cancer is specifically avoided in people with multiple myeloma. Tell the radiologist or the radiology technician about your diagnosis before receiving dye injection into your vein, because this can cause kidney damage in people with myeloma.

  • Positron emission tomography (PET) or PET-CT scan. A PET scan is usually combined with a CT scan (see above), called a PET-CT scan. However, you may hear your doctor refer to this procedure just as a 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. 

  • Bone marrow aspiration and biopsy. These 2 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. This is important for making a diagnosis of myeloma.

    A pathologist then analyzes the sample(s). A pathologist is a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease. The genes in the myeloma are examined by fluorescent in situ hybridization (FISH) to determine if the myeloma is standard or high risk.

    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. Other types of anesthesia may also be used to block the awareness of pain. 

  • Fat pad aspirate. If certain M proteins that are misfolded in a particular way are deposited in body tissues, it can cause organs to stop functioning normally. This condition is called amyloidosis. If amyloidosis is a consideration, then it may be necessary to take a sample of the abdominal fat pad (the collection of fat around a person's abdomen) to be examined under a microscope, called a biopsy.

  • Molecular testing of the tumor. Your doctor may recommend running laboratory tests on a tumor and/or bone marrow sample to identify specific chromosomes (cytogenetics), genes (FISH), proteins, and other factors unique to the tumor as mentioned above. 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 in this guide is Stages. It explains the system doctors use to describe the extent of the disease. Or, use the menu to choose another section to continue reading this guide.  

Multiple Myeloma - Stages

This section has been reviewed and approved by the Cancer.Net Editorial Board, 10/2016

ON THIS PAGE: You will learn about how doctors describe myeloma’s growth or spread. This is called the stage. To see other pages, use the menu.

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 people with newly diagnosed myeloma as being either symptomatic from the disease (having symptoms and signs) or asymptomatic (not having any symptoms). Patients without symptoms are generally watched closely without specific treatment, although therapies are sometimes offered to stop the disease from growing or spreading. This is called active surveillance for smoldering myeloma (see Treatment Options). Patients with symptoms or who are about to develop symptoms need treatment.

The symptoms related to myeloma are described with the mnemonic CRAB. They include hypercalcemia (high blood Calcium), poor Renal or kidney function, Anemia, and Bone pain or bone lesions.

  • Calcium levels are increased. This is defined as a serum calcium level >0.25 mmol/L above the upper limit of normal or a level that is >2.75 mmol/L.

  • Renal problems, identified as a creatinine >173 mmol/L.

  • Anemia is defined as having a low hemoglobin level, which is 2 g/dL below the lower limit of normal or a hemoglobin level that is <10 g/dL.

  • Bone lesions include:

    • lytic lesions (areas of bone damage)

    • osteoporosis (thinning of the bones)

    • compression fracture of the spine

Other symptoms include symptomatic hyperviscosity (thickening of the blood), amyloidosis, and repeated serious bacterial infections (more than 2 episodes in 12 months). Patients with CRAB features require active treatment.

Patients may also be treated, even if they don’t have CRAB features, if any of the following conditions apply:

  • >60% bone marrow plasma cells

  • Kappa-to-lambda ratio >100, based on serum testing, with absolute values >100 mg/L or 10 mg/dL

  • Bone lesions seen on MRI or PET-CT imaging

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 and/or size of the tumor. According to this system, there are 3 stages, called stages I, II, or III (1, 2, or 3). Each stage is further classified into A or B, depending on whether kidney function has been affected. The B classification means that 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 is 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; <4 g/24 h for urinary light chain

    • No bone damage on x-rays or only 1 bone lesion is visible

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 include:

  • Anemia, with a hemoglobin <8.5 g/dL

  • Hypercalcemia

  • Advanced bone damage (3 or more bone lesions)

  • High levels of M protein in the blood or urine

    • M protein >7 g/dL for IgG; >5 g/dL for IgA; >12 g/24 h for urinary light chain

International Staging System

The International Staging System (ISS) is now used more commonly to classify multiple myeloma. It defines the factors that influence patient survival. The ISS is based on data collected from people with multiple myeloma from around the world. The system has 3 stages based on the measurement of serum albumin and the levels of serum β2-M.

Recent efforts have been made to further classify myeloma based on patterns of gene expression in myeloma cells. This is an ongoing area of research.

Stage I: β2-M <3.5 mg/L with a serum albumin of 3.5 g/dL or more

Stage II: Either of these 2 criteria:

  • β2-M between 3.5 mg/L and 5.5 mg/dL

  • Albumin <3.5 g/dL

Stage III: β2-M >5.5 mg/L

This system has recently been revised to include serum lactase dehydrogenase (LDH) and high-risk gene abnormalities defined by FISH. It is most commonly used to predict prognosis. Higher blood levels of LDH indicate a poorer prognosis. Abnormalities of chromosomes (as defined by the results of cytogenetic testing) in the cancer cells may also show how aggressive the cancer is and influence how the disease progresses.

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 M protein. Doctors generally monitor these people closely, and active treatment does not begin unless the person starts to experience symptoms and/or shows signs of damage to major organs, called end organ damage; this is so-called symptomatic myeloma.

Monoclonal gammopathy of undetermined significance (MGUS)

This condition occurs when people have a low level of M protein, meaning there are small amounts of abnormal plasma cells, but they do not have any other evidence of myeloma, such as bone damage, excessive plasma cells in the marrow, or low numbers of components of the blood count, such as red blood cells, white blood cells, and/or platelets. 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 regularly monitored for health changes by his or her doctor.

Smoldering multiple myeloma (SMM) or asymptomatic myeloma

People who are diagnosed with SMM have higher levels of M protein and more plasma cells in the bone marrow than people with MGUS. However, there is still no evidence of symptoms or signs of myeloma, such as significant bone disease or anemia. A person with SMM may be prescribed bisphosphonates for symptoms of osteoporosis or osteopenia and/or a new therapy being studied in a clinical trial. Osteopenia is condition in which a person has a low density of bone minerals. Most people with SMM eventually develop myeloma. For this reason, the health of people with SMM should be closely monitored by their doctors, who may recommend starting treatment when there is progression of disease and especially to patients who are at the risk of developing symptoms within 18 months to 2 years.

Prognosis

The 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 people with multiple myeloma. Some of the current approaches for evaluating prognosis include:

  • High levels of β2-M may indicate that a large number of myeloma cells is present and that 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 (cytogenetics) in the cancer cells may show how aggressive the cancer is. This approach to testing the genetics of the myeloma includes FISH.

  • 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 specific treatment plan. The next section in this guide is Treatment Options. Or, use the menu to choose another section to continue reading this guide.  

Multiple Myeloma - Treatment Options

This section has been reviewed and approved by the Cancer.Net Editorial Board, 10/2016

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.

This section tells you the treatments that are the standard of care for this type of cancer. “Standard of care” means the best treatments known. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to treatment. Doctors want to learn if it is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug, a new combination of standard treatments, or new doses of standard drugs or other treatments. Your doctor can help you consider all your treatment options. Research for new myeloma treatments is very active, and many clinical trials are offered. To learn more about clinical trials, see the About 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. Cancer care teams also include a variety of other health care professionals, including physician assistants, oncology nurses, social workers, pharmacists, counselors, dietitians, and others.

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.

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

People with early-stage myeloma and no symptoms, called SMM (see Stages), may simply be closely monitored by the doctor through checkups. This approach is called active surveillance or watchful waiting. As noted previously, if there is evidence of bone thinning, or osteoporosis, periodic infusions of bisphosphonates to reverse this process may be recommended. There are also clinical protocols used to evaluate whether using targeted therapy or immunotherapy can prevent or delay myeloma from developing into a disease that requires treatment. 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 2 years. 

Overview of treatment options for patients with symptoms

Treatment for people with symptomatic myeloma includes both treatment for the disease as well as supportive therapy to improve quality of life, such as by relieving symptoms and maintaining good nutrition. Disease-directed treatment typically includes drug therapy, such as targeted therapy and/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.

  • Induction therapy for rapid control of cancer and to help relieve symptoms

  • Consolidation with more chemotherapy or stem cell transplant

  • Maintenance therapy over a prolonged period to prevent cancer recurrence

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. In recent years, targeted treatment, sometimes called novel therapy, has proven to be increasingly successful at controlling myeloma and improving prognosis. Researchers continue to investigate new and evolving drugs for this disease in clinical trials.

Recent studies show that not all tumors have the same targets. To find the most effective treatment, your doctor may run tests on cancer cells to identify genes, proteins, and other factors. This helps doctors better match each patient with the most effective treatment whenever possible.

  • 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 so they attack cancer cells. They starve the cancer cells by blocking the formation of new blood vessels, a process called angiogenesis.

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

  • Panobinostat (Farydak) is an inhibitor of the enzyme histone deacetylase (HDAC). HDACs help keep the DNA tightly coiled, while panobinostat helps uncoil the DNA and activate genes that stop or slow the growth of cancer cells. It also blocks an escape route called the aggresome.

  • Elotuzumab (Empliciti) and daratumumab (Darzalex) are monoclonal antibodies that bind to myeloma cells and label them for removal by the patient’s own immune system.

Thalidomide, lenalidomide, and bortezomib are targeted, novel therapies approved to treat newly diagnosed patients. Lenalidomide, pomalidomide, bortezomib, carfilzomib, panobinostat, ixazomib, elotuzumab, and daratumumab are effective for treating recurrent myeloma. Targeted therapies may also be used in combination with chemotherapy or steroid medications (see below), because 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 as initial treatment. Clinical trials are exploring whether the combination of lenalidomide, bortezomib, and dexamethasone may be as effective as lenalidomide, bortezomib, and dexamethasone followed by stem cell transplant (see below).

Thalidomide, lenalidomide, and bortezomib can also be effectively used as maintenance therapy to extend the response to the initial therapy 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 and/or bortezomib increases how long patients survive and extends how long they live without active myeloma. Maintenance therapy has to be used with some caution, although recent studies have shown significant improvement with survival using this approach. Find out more about the basics of maintenance therapy.

In addition, many research studies are taking place now to find out more about specific molecular targets and new treatments directed at them. It is also important to talk with your doctor about possible side effects for a specific medication and how they can be better managed. Learn more about the basics of 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 gets into the bloodstream to reach cancer cells throughout the body. Systemic chemotherapy is not targeted, in the sense that these drugs typically affect the cancer cells as a whole and their ability to divide. 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 1 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 include cyclophosphamide (Cytoxan, Neosar), doxorubicin (Adriamycin, Doxil), melphalan (Alkeran), etoposide (Toposar, VePesid), cisplatin (Platinol), and carmustine (BiCNU).

Often, more than 1 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 novel targeted therapy called bortezomib is approved by the U.S. Food and Drug Administration (FDA) for the initial treatment of multiple myeloma. This is because this combination 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 the basics of 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 with targeted novel therapy or chemotherapy (see above).

For example, lenalidomide (Revlimid) and dexamethasone as induction and maintenance therapy is recommended for those who are not able to have stem cell transplantation. Adding bortezomib (Velcade) to this combination has recently been shown to be effective in a clinical trial. In addition, most patients with myeloma receive monthly infusions of bisphosphonate therapy, which are drugs that help to prevent the progression of bone disease from myeloma. Learn more about the basics of 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 2 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 (usually melphalan) and then allow replacement blood stem cells to create healthy bone marrow.

Learn more about the basics of 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 in order to control pain. However, using radiation therapy is not an easy 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 affect 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 the basics of radiation therapy.

Surgery

Surgery is not usually a disease-directed treatment option for multiple myeloma, but it may be used to relieve symptoms (see below). Surgery is used to treat bone disease, especially if there are fractures, and recent plasmacytomas, especially if they occur outside the bone.

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 is any treatment that focuses on reducing symptoms, improving quality of life, and supporting patients and their families. Any person, regardless of age or type and stage of cancer, may receive palliative care. It works best when palliative care is started as early as needed in the cancer treatment process. 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, emotional support, 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 and known as IVIG) to treat or prevent infections.

  • Pain medications, or analgesics, are given to patients who need help managing bone pain. They can include a wide range of drugs, from acetaminophen (Tylenol) to opiates. Non-steroidal anti-inflammatory drugs (NSAIDs) 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 patients who are being treated with a combination of an immunomodulatory agent, such as thalidomide (Thalomid), 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 also sometimes to treat painful neuropathy that can be caused by the myeloma itself or by treatments for myeloma.

  • Antacids or proton pump inhibitors are frequently given to patients who are taking steroids to prevent or treat gastrointestinal problems.

  • Plasmapheresis is a procedure used to reduce the thickness of the blood and relieve the related symptoms. During this procedure, blood is taken from a vein. The plasma is then removed from the body after it is separated from the red and white blood cells. Plasma is the liquid part of the blood. The blood cells are then mixed with a plasma substitute, usually an albumin solution, and placed back into the patient. This procedure is often done using a blood cell separator.

  • 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 is very important. Patients are encouraged to drink water and other healthy fluids, so the body can flush the kidneys and help them filter impurities from the blood.

  • A balanced diet that is high in calories and protein helps prevent fatigue and infection, as does getting plenty of rest and reducing stress.

  • Emollient/moisturizing cream and supplements may also help with specific side effects such as peripheral neuropathy.

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 investigated to relieve pain, restore lost height due to a collapsing vertebra, and strengthen the spine. One such procedure is 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 vertebroplasty, which involves 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 palliative 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 can be addressed as quickly as possible. Learn more about palliative care

Refractory myeloma

The disease is called relapsed and refractory myeloma if the cancer no longer responds to the most recent treatment. If this happens, it is a good idea to talk with doctors who have experience in treating refractory myeloma. Doctors can have different opinions about the best standard treatment plan. Also, clinical trials might be an important option.

Sometimes drugs that have gone through advanced phases of clinical trial and are awaiting FDA approval are made more readily available to patients with refractory myeloma through FDA’s Expanded Access Clinical Trial Program. One such drug that has gone through this process is daratumumab (Darzalex). It was first approved in 2015 to be used alone to treat relapsed and refractory myeloma after other treatments had failed. Most recently, in November 2016, the FDA approved the use of daratumumab in combination with lenalidomide and dexamethasone or with bortezomib and dexamethasone to treat people who have already received at least 1 previous treatment. You may want to talk to your physician about availability of such drug(s). 

Learn more about getting a second opinion before starting treatment, so you are comfortable with your chosen treatment plan.

For people with refractory myeloma, palliative care may also be important to help relieve symptoms and side effects.

For most patients, a diagnosis of relapsed and refractory myeloma 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.

Remission and the chance of recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. It’s important to talk with your doctor about the possibility of the cancer returning, which is almost certain with myeloma, despite recent advances in therapy. Understanding your 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 treatments described above such as targeted therapy and chemotherapy, but they may be used in a different combination or given at a different pace. Recent advances in targeted, novel therapy mean that the chances of effective treatment for relapsed disease are increasing.

Your doctor may also suggest clinical trials that are studying new ways to treat recurrent or relapsed myeloma. There are multiple drugs currently being researched in the late stages of clinical trials that have shown promise as treatments for recurrent or relapsed myeloma. See the Latest Research section for more information. Whichever treatment plan you choose, palliative care will also be important for relieving symptoms and side effects.

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.

If treatment fails

Recovery from and a cure for myeloma are unlikely. The disease is still considered incurable despite recent progress. If the cancer cannot be controlled even with the newer treatments available, the disease may be called advanced or terminal.

This diagnosis is stressful, and advanced cancer 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 6 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 in this guide is About Clinical Trials. It offers more information about research studies that are focused on finding better ways to care for people with cancer. Or, use the menu to choose 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, 10/2016

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.

What are clinical trials?

Doctors and scientists are always looking for better ways to care for patients with multiple myeloma. To make scientific advances, doctors create research studies involving patients as volunteers, called clinical trials. In fact, every drug that is now approved by the U.S. Food and Drug Administration (FDA) was tested in clinical trials.

Many clinical trials focus on new treatments. Researchers want to learn if a new treatment is safe, effective, and possibly better than the treatment doctors use now. Broadly speaking, 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 can be some of the first to get a treatment before it is available to the public. There is no guarantee that the new treatment will be safe, effective, or better than what doctors use now; however, recent successes in a growing number of clinical trials in the treatment of myeloma and resulting FDA approvals is encouraging.

Some clinical trials study new ways to relieve symptoms and side effects during treatment. Others study ways to manage the late effects that may happen a long time after treatment. Talk with your doctor about clinical trials for symptoms and side effects. There are also clinical trials studying ways to prevent cancer. In addition, there are ongoing studies for patients with SMM to try to prevent it from progressing to active disease.

Deciding to join a clinical trial

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, in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” However, placebos are usually combined with standard treatment in most cancer clinical trials. In myeloma therapy, this is always the case due to the nature of the disease. 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.

Patient safety and informed consent

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.

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. 

Finding a clinical trial

Research through clinical trials is ongoing for all types of cancer. For specific topics being studied for multiple myeloma, learn more in the Latest Research section.

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.

In addition, this website offers free access to a video-based educational program about cancer clinical trials, located outside of this guide.

The next section in this guide is Latest Research. It explains areas of scientific research currently going on for this type of cancer. Or, use the menu to choose another section to continue reading this guide.    

Multiple Myeloma - Latest Research

This section has been reviewed and approved by the Cancer.Net Editorial Board, 10/2016

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.

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 that are 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 available clinical trials.

  • Expanded use of stem cell transplantation. Although autologous (AUTO) stem cell transplantation is a standard treatment option for myeloma, researchers are studying the benefits of tandem (double) AUTO transplantations, ALLO transplantations, and tandem AUTO mini-allogeneic transplantations in very specific patients. AUTO means the stem cells are from the patient. ALLO means that the stem cells came from a donor. The goal of these studies is to establish how these approaches fit best into doctors’ knowledge about current treatments.  For more information about transplantation, read the Treatment Options section.

  • New drugs. A variety of novel drugs are being studied for the treatment of relapsed myeloma and relapsed, refractory myeloma, including the following examples, with many more being studied:

    • 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. Many of these drugs are being studied for multiple myeloma. One such drug, called isatuximab or SAR650984, is being studied. An anti-CD138 monoclonal antibody (indatuximab ravtansine) is also being studied. Elotuzumab and daratumumab were approved by the FDA in November 2015 and have both been shown to be highly effective, especially when combined.

    • HDAC inhibitors are an area of active research, both as single drugs and in combination with other drug therapy. Drugs in this category include panobinostat, which is FDA approved, ACY1215, and AC241, which has shown encouraging results.

    • Lenalidomide and dexamethasone with or without elotuzumab, lenalidomide and dexamethasone with or without ixazomib (Ninlaro), and lenalidomide and dexamethasone with or without carfilzomib have all finished phase III clinical trials. These studies have shown substantial clinical benefit, leading to FDA approval.

    • The fibroblast growth factor receptor 3 (FGFR3) is expressed in approximately 15% of patients with myeloma. FGFR3 is involved in cell growth, angiogenesis, and wound healing. Drugs that inhibit FGFR3 are being developed to help control cancer in these patients.

    • Two proteasome inhibitors, called oprozomib and marizomib (NPI-0052), have also been evaluated in clinical trials, with early results showing promise, particularly with marizomib combined with pomalidomide.

    • 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 normal 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 have been developed and are being studied in various settings, including:

    • Bortezomib and lenalidomide in combination with dexamethasone

    • Bortezomib, cyclophosphamide, and dexamethasone

    • Carfilzomib, lenalidomide, and dexamethasone

    • Ixazomib, lenalidomide, and dexamethasone

    • Pomalidomide, bortezomib, and dexamethasone

    • Carfilzomib, pomalidomide, and dexamethasone

    • Pomalidomide, ixazomib, and dexamethasone

    • Pomalidomide, dexamethasone, and clarithromycin (Biaxin)

  • Immunotherapy. This type of therapy is designed to boost the body’s natural defenses 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.

Checkpoint inhibitor therapies include antibodies to block PD-L1 on multiple myeloma cells and PD-1 on immune cells. PD-1 is found on the surface of T-cells, which are a type of white blood cell that directly helps body’s immune system fight disease. Because PD-1 keeps the immune system from destroying cancer cells, blocking PD-1 allows the immune system to better eliminate the disease. Chimeric antigen receptor (CAR) T-cells are another form of immune therapy in which the patient’s own immune cells are removed, modified to target their own myeloma cells, and then put back into the body to fight the myeloma. Learn more about the basics of immunotherapy.

  • Cytogenetics. Cytogenetics, which is the study of genetic changes in cells, and molecular studies may be performed on a tissue sample removed during a biopsy to find out how aggressive the cancer is. In myeloma, the genes in plasma cells are routinely studied using FISH to identify standard and high-risk disease. This may help guide treatment. More genetic tests are being developed, usually in ongoing research studies.

  • Minimal residual disease (MRD). As treatments have become increasingly effective in treating myeloma, new approaches to measure how well a treatment works have been developed, including MRD. This parameter may help guide treatment but is usually only used in research.

  • Palliative care. A limited number of clinical trials are underway to find better ways of reducing symptoms and side effects of current myeloma treatments to improve patients’ comfort and quality of life.

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 in this guide is Coping with Treatment. It offers some guidance in how to cope with the physical, emotional, and social changes that cancer and its treatment can bring. Or, use the menu to choose 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, 10/2016

ON THIS PAGE: You will learn more about coping with the physical, emotional, social, and financial effects of cancer and its treatment. This page includes several links outside of this guide to other sections of this website. To see other pages, use the menu.

Every cancer treatment can cause side effects or changes to your body and how you feel. For many reasons, people don’t experience the same side effects even when given the same treatment for the same type of cancer. This can make it hard to predict how you will feel during treatment.

As you prepare to start cancer treatment, it is normal to fear treatment-related side effects. It may help to know that your health care team will work to prevent and relieve side effects. Doctors call this part of cancer treatment “palliative care.” It is an important part of your treatment plan, regardless of your age or the stage of disease.

Coping with physical side effects

Common physical side effects from each treatment option for multiple myeloma are described in the Treatment Options section. Learn more about side effects of cancer and its treatment, along with ways to prevent or control them. Changes to your physical health depend on several factors, including the cancer’s stage, the length and dose of treatment, and your general health.

Sometimes, physical side effects can last after treatment ends. Doctors call these long-term side effects. They call side effects that occur months or years after treatment late effects. Treating long-term side effects and late effects is an important part of survivorship care. Learn more by reading the Follow-up Care section of this guide or talking with your doctor.

Coping with emotional and social effects

You can have emotional and social effects as well as physical effects after a cancer diagnosis. This may include dealing with difficult emotions, such as anxiety or anger, or managing your stress level. Sometimes, patients have problems expressing how they feel to their loved ones, or people don’t know what to say in return.

Patients and their families are encouraged to share their feelings with a member of their health care team. You can also find coping strategies for emotional and social effects in a separate section of this website. This section includes many resources for finding support and information to meet your needs.

Coping with financial effects

Cancer treatment can be expensive. It is often a big source of stress and anxiety for people with cancer and their families. In addition to treatment costs, many people find they have extra, unplanned expenses related to their care. For some people, the high cost stops them from following or completing their cancer treatment plan. This can put their health at risk and may lead to higher costs in the future. Learn more about managing financial considerations, in a separate part of this website.

Caring for a loved one with cancer

Family members and friends often play an important role in taking care of a person with myeloma. This is called being a caregiver. Caregivers can provide physical, practical, and emotional support to the patient, even if they live far away.

Caregivers may have a range of responsibilities on a daily or as-needed basis. Below are some of the responsibilities caregivers take care of:

  • Providing support and encouragement

  • Giving medications

  • Helping manage symptoms and side effects

  • Coordinating medical appointments

  • Providing a ride to appointments

  • Assisting with meals

  • Helping with household chores

  • Handling insurance and billing issues

Learn more about caregiving.

Talking with your health care team about side effects

Before starting treatment, talk with your doctor about possible side effects. Ask:

  • Which side effects are most likely?

  • When are they are likely to happen?

  • What can we do to prevent or relieve them?

Be sure to tell your health care team about any side effects that happen during treatment and afterward, too. Tell them even if you don’t think the side effects are serious. This discussion should include physical, emotional, and social effects of cancer.

Also, ask how much care you may need at home and with daily tasks during and after treatment. This can help you make a caregiving plan.

The next section in this guide is Follow-up Care. It explains the importance of checkups after cancer treatment is finished. Or, use the menu to choose another section to continue reading this guide.  

Multiple Myeloma - Follow-Up Care

This section has been reviewed and approved by the Cancer.Net Editorial Board, 10/2016

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

Care for people diagnosed with myeloma doesn’t end when active treatment has finished. Your health care team will continue to check to make sure the cancer has not returned, manage any side effects, and monitor your overall health. This is called follow-up care.

Your follow-up care may include regular physical examinations, medical tests, or both. Doctors want to keep track of your recovery in the months and years ahead. Your doctor may recommend maintenance therapy to prevent cancer recurrence. 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 change how bisphosphonate is used in the future.

Learn more about the importance of follow-up care.

Watching for recurrence

One goal of follow-up care is to check for a recurrence. Over time, myeloma recurs and arises because small areas of this cancer may remain undetected and resistant to treatment in the body. In turn, these cells may increase in number until they show up on test results or cause signs or symptoms. During follow-up care, a doctor familiar with your medical history can give you personalized information about your risk of recurrence. Your doctor will also ask specific questions about your health. Some people may have blood tests or imaging tests as part of regular follow-up care, but testing recommendations depend on several factors including the type and stage of cancer originally diagnosed and the types of treatment given. For myeloma, this typically includes blood tests, periodic radiologic testing, and bone marrow evaluation every 1 to 3 months. Treatment usually continues in myeloma, so this is usually integrated with ongoing surveillance.

Managing long-term and late side effects

Most people expect to experience side effects when receiving treatment. However, it is often surprising to survivors that some side effects may linger beyond the treatment period. These are called long-term side effects. In addition, other side effects called late effects may develop months or even years afterwards. Long-term and late effects can include both physical and emotional changes.

Talk with your doctor about your risk of developing such side effects based on the type of cancer, your individual treatment plan, and your overall health. If you had a treatment known to cause specific late effects, you may also have certain physical examinations, scans, or blood tests to help find and manage them.

Keeping personal health records

You and your doctor should work together to develop a personalized follow-up care plan. Be sure to ask about any concerns you have about your future physical or emotional health. ASCO offers forms to help create a treatment summary to keep track of the cancer treatment you received and develop a survivorship care plan once treatment is completed.

This is also a good time to decide who will lead your follow-up care. Some survivors continue to see their oncologist, while others transition back to the general care of their family doctor or another health care professional. This decision depends on several factors, including the type and stage of cancer, side effects, health insurance rules, and your personal preferences.

If a doctor who was not directly involved in your cancer care will lead your follow-up care, be sure to share your cancer treatment summary and survivorship care plan forms with him or her, as well as all future health care providers. Details about your cancer treatment are very valuable to the health care professionals who will care for you throughout your lifetime.

The next section in this guide is Survivorship. It describes how to cope with challenges in everyday life after a cancer diagnosis. Or, use the menu to choose another section to continue reading this guide.

Multiple Myeloma - Survivorship

This section has been reviewed and approved by the Cancer.Net Editorial Board, 10/2016

ON THIS PAGE: You will read about how to with challenges in everyday life after a cancer diagnosis. To see other pages, use the menu.

What is survivorship?

The word “survivorship” means different things to different people. Common definitions include:

  • Having no signs of cancer after finishing treatment.

  • Living with, through, and beyond cancer. According to this definition, cancer survivorship begins at diagnosis and includes people who continue to have treatment over the long term, to either reduce the risk of recurrence or to manage chronic disease.

Survivorship is one of the most complicated parts of having cancer. This is because it is different for everyone.

Survivors may experience a mixture of strong feelings, including joy, concern, relief, guilt, and fear. Some people say they appreciate life more after a cancer diagnosis and have gained a greater acceptance of themselves. Others become very anxious about their health and uncertain of how to cope with everyday life.

Survivors may feel some stress when frequent visits to the health care team end following treatment. Often, relationships built with the cancer care team provide a sense of security during treatment, and people miss this source of support. This may be especially true as new worries and challenges surface over time, such as any late effects of treatment, emotional challenges including fear of recurrence, sexuality and fertility concerns, and financial and workplace issues.

Every survivor has individual concerns and challenges. With any challenge, a good first step is being able to recognize your fears and talk about them. Effective coping requires:

  • Understanding the challenge you are facing,

  • Thinking through solutions,

  • Asking for and allowing the support of others, and

  • Feeling comfortable with the course of action you choose.

Many survivors find it helpful to join an in-person support group or an online community of survivors. This allows you to talk with people who have had similar first-hand experiences. Other options for finding support include talking with a friend or member of your health care team, individual counseling, or asking for assistance at the learning resource center of the center where you received treatment.

Changing role of caregivers

Family members and friends may also go through periods of transition. A caregiver plays a very important role in supporting a person diagnosed with cancer, providing physical, emotional, and practical care on a daily or as-needed basis. Many caregivers become focused on providing this support, especially if the treatment period lasts for many months or longer.

However, as treatment changes, the caregiver's role often changes. Eventually, the need for caregiving related to the cancer diagnosis will become much less or come to an end. Caregivers can learn more about adjusting to life after caregiving in this article.

A new perspective on your health

For many people, survivorship serves as a strong motivator to make positive lifestyle changes.

People recovering from multiple myeloma are encouraged to follow established guidelines for good health, such as not smoking, limiting alcohol, eating well, and managing stress. Regular physical activity can help rebuild your strength and energy level. Your health care team can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about making healthy lifestyle choices.

In addition, it is important to have recommended medical checkups and tests (see Follow-up Care) to take care of your health. Cancer rehabilitation may also be recommended, and this could mean any of a wide range of services such as physical therapy, career counseling, pain management, nutritional planning, and/or emotional counseling. The goal of rehabilitation is to help people regain control over many aspects of their lives and remain as independent and productive as possible.

Talk with your doctor to develop a survivorship care plan that is best for your needs.

Looking for More Survivorship Resources?

For more information about cancer survivorship, explore these related items. Please note these links will take you to other sections of Cancer.Net:

  • ASCO Answers Cancer Survivorship Guide: Get this 44-page booklet that helps people transition into life beyond treatment. It includes blank treatment summary and survivorship care plan forms. The booklet is available as a PDF, so it is easy to print out.

  • Cancer.Net Patient Education Video: View a short video led by an ASCO expert that provides information about what comes next after finishing treatment.

  • Survivorship Resources: Cancer.Net offers an entire area of this website with resources to help survivors, including for survivors in different age groups.

The next section offers Questions to Ask the Doctor to help start conversations with your cancer care team. Or, use the menu to choose 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, 10/2016

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.

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.

Questions to ask after getting a diagnosis

  • 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?

Questions to ask about choosing a treatment and managing side effects

  • What are my treatment options?

  • What clinical trials are available for 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?

  • What are the possible side effects of this treatment, both in the short term and long term?

  • Who will be part of my health care team, and what does each member do?

  • Who will be leading my overall treatment?

  • Should I get a second opinion?

  • 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 of cancer care, who can help me?

Questions to ask about planning follow-up care

  • What is the chance that the cancer will come back? Should I watch for specific signs or symptoms?

  • What long-term side effects or late effects are possible based on the cancer treatment I received?

  • What follow-up tests will I need, and how often will I need them?

  • How do I get a treatment summary and survivorship care plan to keep in my personal records?

  • Who will be leading my follow-up care?

  • What support services are available to me? To my family?

  • Where can I get more information?

  • Whom should I call with questions or problems?

The next section in this guide is Additional Resources. It offers some more resources on this website beyond this guide that may be helpful to you. Or, use the menu to choose another section to continue reading this guide.

Multiple Myeloma - Additional Resources

This section has been reviewed and approved by the Cancer.Net Editorial Board, 10/2016

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.

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 to select another section to continue reading this guide.