Multiple Myeloma Treatment Overview

Receiving a multiple myeloma diagnosis can feel overwhelming. The International Myeloma Foundation (IMF) recommends consulting a myeloma specialist to determine the best course of action. The next steps may include baseline testing, staging, and prognostic classification.

When to Treat Multiple Myeloma​

Explore when treatment is recommended below.

Monoclonal Gammopathy of Undetermined Significance (MGUS)

MGUS may occur before asymptomatic myeloma. A small amount of blood immunoglobulin (M-protein) indicates myeloma, but tests show no other criteria. At this stage, patients do not need treatment. Patients with MGUS may never develop smoldering multiple myeloma (SMM) or active myeloma.

Asymptomatic Myeloma

Asymptomatic, smoldering, or indolent myeloma presents no symptoms, but there may be diagnostic criteria. A patient has an M-protein (IgG or IgA) level of at least 3 grams per deciliter in the blood or 500 milligrams per 24 hours in the urine and/or monoclonal plasma cells comprising between 10% and 60% of the bone marrow. However, the patient lacks myeloma-defining events (MDE) or amyloidosis.

Myeloma-defining events include: 

• CRAB criteria (elevated calcium, renal failure, anemia, and bone lesions).
• Bone marrow plasma cells greater than or equal to 60%.
• A serum free light chain (FLC) ratio of 100 or more with an involved FLC level greater than or equal to 100 milligrams per liter.
• At least one focal lesion on an MRI.

Doctors follow a “watchful waiting” approach for asymptomatic myeloma, monitoring individuals without treatment. Patients might need regular checkups and blood counts, urinalysis, or imaging tests to track progression. However, some high-risk SMM cases may warrant early intervention, which is typically done through clinical trials.

Active Myeloma

Symptomatic or active myeloma requires immediate treatment. At this stage, patients may have increased abnormal plasma cells in their bone marrow, bone, or soft tissue. An MRI may show one or more areas of bone damage. Individuals may meet multiple CRAB criteria or present with increased MDEs. 

What Is the Treatment for Multiple Myeloma?

The following sections go into greater detail about multiple myeloma treatment plans.

Targeted Therapy

Targeted therapy uses medications designed to target certain chemicals in cancer cells. By blocking these chemicals, these treatments can help eliminate cancer cells. This tailored method can be a vital part of treatment plans, focusing on the unique characteristics of cancer.

A myeloma specialist may prescribe medication like:

• Proteasome inhibitors (PIs): Proteasomes break down damaged or unnecessary cell proteins. PIs prevent proteasomes from breaking down excess proteins that can kill myeloma cells. 
• Immunomodulatory drugs (IMiDs): These medications modify the immune system. They stop myeloma growth by activating immune system cells.
• Monoclonal antibodies (MAbs): Manufactured MAbs act like immune system antibodies. They target and kill specific cancer cells. 

Immunotherapy

The immune system defends the body from illnesses, but cancer cells often find ways to evade detection. Immunotherapy aids the immune cells in recognizing and attacking these hidden cancer cells. It helps to restore the body's natural defenses.

CAR-T Cell Therapy

CAR-T cell therapy harnesses the immune system to target myeloma cells. Medical professionals collect a sample of white blood cells, including T cells, and send them to a specialized lab. There, technicians genetically modify the T cells to produce a chimeric antigen receptor (CAR) on their surface. This receptor helps them recognize and attack myeloma cells. Once infused back into the body, the CAR-T cells multiply and seek out and destroy myeloma cells. Yet, some patients may not respond to CAR T-cell therapy.

Chemotherapy

Chemotherapy employs powerful medications to target and kill dividing cancer cells, including myeloma cells. This treatment plays an essential role in managing and reducing cancer cell growth.

Autologous Stem Cell Transplant

An autologous stem cell transplant (ASCT) is a procedure used to restore blood-forming stem cells after high-dose chemotherapy (HDT). Unlike a bone marrow transplant, which collects stem cells directly from the bone marrow, ASCT uses peripheral blood stem cells (PBSCs) harvested from the bloodstream. 

To collect these cells, the patient receives a mobilizing agent to move stem cells from the bone marrow into the bloodstream. Medical professionals collect these cells through a process called apheresis. After collection, the patient undergoes HDT, which destroys both cancer cells and healthy blood-forming cells in the bone marrow.

To help the bone marrow recover, doctors infuse the previously collected healthy stem cells back into the patient, and they travel to the bone marrow and begin producing new blood cells. This process, known as engraftment, helps restore the body’s ability to fight infections, carry oxygen, and clot blood. 

ASCT is a standard treatment for multiple myeloma and some other blood cancers. It allows patients to tolerate higher doses of chemotherapy while helping the bone marrow recover.

Radiation Therapy

Radiation therapy uses energy beams to target and kill cancer cells. This treatment can effectively shrink myeloma growth, such as a plasmacytoma, and may relieve pain or prevent bone damage. 

Other Myeloma Treatments

Additional treatments for myeloma include:

• Alkylating agents: These drugs attach to DNA to prevent cancer cells from replicating.
• Corticosteroids: Doctors prescribe corticosteroids to fight inflammation. They relieve the side effects of chemotherapy and can fight cancer cells when combined with other medications. Learn more about the steroids used in myeloma treatment. 
• Bisphosphonates: This supportive care treatment helps combat bone health issues. Myeloma patients may experience various bone issues, including lytic lesions (destruction of an area of bone), weak bones, and fractures or breaks.

Talk to Your Healthcare Team About Treatment Options

When you consult your doctor, you can learn when and if you should treat myeloma as a newly diagnosed patient. If you have undergone induction therapy, you and your healthcare team can assess whether you need maintenance therapy or a new intervention. If your disease has progressed despite initial treatments, you may need early relapse treatment.

You can explore more support resources from the IMF, including our Myeloma Minute newsletter, for the latest news and research. Additionally, find specific information about multiple myeloma medications.

What's Next?