Multiple Myeloma

What myeloma is — in plain words

Inside your bone marrow live plasma cells — a type of white cell whose job is to make antibodies that fight infection. In myeloma, one plasma cell becomes abnormal and starts making millions of copies of itself. All those copies produce one single, useless antibody (called a paraprotein or M-protein) in large amounts. Meanwhile, they crowd out the healthy marrow and weaken the bones around them.

That explains almost all the problems myeloma causes: bone pain, anaemia, kidney damage, and a curious vulnerability to infection despite a high antibody level (because all those antibodies are the same useless one).

Who tends to get it

Myeloma is largely a disease of older adults — the average age at diagnosis is in the late sixties. It's slightly commoner in men. We rarely identify a clear cause in any one patient. Many patients first pass through a precursor state called MGUS (monoclonal gammopathy of undetermined significance), found on a blood test done for some other reason, which most often never progresses.

How myeloma presents — the CRAB criteria

Doctors use a mnemonic — CRAB — to describe the four classic damage features. Any one of them, in the right setting, points to active myeloma needing treatment.

In addition, newer criteria treat very high plasma cell percentages, very abnormal free light chain ratios, and more than one bone lesion on MRI as reasons to start treatment even before CRAB damage appears.

"Twenty years ago, the average survival in myeloma was three years. Today, many of my patients are well a decade after diagnosis. The disease hasn't gone away — but the tools we have to control it have transformed."

How we diagnose myeloma

Diagnosis depends on testing the blood, the urine, the bone marrow and the bones themselves.

• Serum protein electrophoresis (SPEP) and immunofixation — identifies the abnormal paraprotein in the blood and its type (IgG kappa, IgA lambda, etc.).
• Serum free light chains (sFLC) and ratio — measures the light chain portion of the antibody; vital in light-chain-only myeloma where SPEP can be near-normal.
• 24-hour urine protein and Bence Jones protein — measures light chains spilling into the urine.
• Bone marrow aspirate and biopsy — confirms the percentage of plasma cells. Cytogenetics by FISH on the bone marrow identifies high-risk features (such as t(4;14), t(14;16), del(17p), 1q gain).
• Whole-body low-dose CT, or whole-body MRI, or PET-CT — the modern way to look for bone lesions, far more sensitive than the old skeletal X-ray survey.
• CBC, calcium, creatinine, albumin, beta-2 microglobulin, LDH — for the diagnosis and for staging by the Revised International Staging System (R-ISS).

How myeloma is treated — modern combinations

Today's myeloma treatment is built on combining drugs from different classes. The classes work in different ways, and together they hit the disease harder than any one drug alone.

A common first-line regimen is VRd (bortezomib, lenalidomide, dexamethasone) or D-VRd (adding daratumumab). Treatment is typically given for several months as induction, followed — for eligible patients — by an autologous stem cell transplant, then a maintenance phase.

Autologous stem cell transplant

For patients fit enough (broadly, under 70 with good organ function and no major comorbidity), autologous stem cell transplant remains a powerful tool. Your own stem cells are collected after induction, then a high dose of melphalan is given to wipe out remaining myeloma, and the stem cells are infused back to rebuild your marrow. The hospital stay is around two to three weeks, recovery takes a few months, and the deep response it produces often lasts years. Read more about transplant →

Supportive care — just as important as the chemo

• Bone protection with monthly zoledronic acid or denosumab to strengthen bones and prevent fractures.
• Pain control for bone pain — including, where needed, vertebroplasty or radiotherapy to a painful lesion.
• Infection prevention with vaccinations, sometimes antiviral prophylaxis, and prompt treatment of fevers.
• Kidney protection with good hydration and avoidance of contrast and NSAIDs where possible.
• Clot prevention with aspirin or low-molecular-weight heparin during IMiD-based therapy.

If the disease comes back

Myeloma typically responds beautifully to first-line treatment, then, eventually, relapses. The good news is we have many more lines now than we used to. Second-line and later combinations may use different proteasome inhibitors, different IMiDs, different antibodies, and increasingly newer options like bispecific antibodies (teclistamab, elranatamab) and CAR-T cell therapy at specialist centres. Each line buys time.

What outcomes look like — honestly

Myeloma is not yet curable for most patients, but median survival has roughly tripled in two decades. Many patients today live a decade or longer with good quality of life. Outcomes depend on age and fitness, the genetics of the disease (standard-risk vs high-risk by FISH), the depth of response to treatment, and access to the full modern armoury of drugs. We'll be honest with you about your specific situation.

Daily life with myeloma

Most patients on maintenance therapy work, travel, attend family functions, and live well. The main practical adaptations are around bone safety (avoiding high-impact activities and falls), infection awareness (prompt attention to fevers), and the rhythm of regular clinic visits for monitoring. Fasting during Ramadan is often feasible — we'll discuss it case by case.