A multiple myeloma diagnosis often brings many questions, and one of the toughest parts to accept is that treatment is a process, not a single event. It involves a path with many stops, which you handle with your care team over months or years ahead.
Multiple myeloma is a cancer of plasma cells, a type of white blood cell found in your bone marrow. It’s one of the more treatable blood cancers, but it is not yet curable for most people.
Why Is Multiple Myeloma Treated in Stages?
Instead of receiving one course of therapy, you typically move through a series of treatments over time. Doctors call each treatment plan a “line of therapy.” When one stops working, you and your care team consider the next step.
To explain this journey, two specialists were consulted: Adeel Khan, MD, a hematologist-oncologist and epidemiologist at UT Southwestern Medical Center in Dallas, and Tulio Rodriguez, MD, a hematologist-oncologist and director of the Bone Marrow Transplant and Cellular Therapy Program at City of Hope Cancer Center Chicago.
Khan said. Doctors must decide which treatments to use and when.
There is no single best sequence. As myeloma can change over time, each treatment aims to control the disease while preserving future options.
Doctors also consider relapse likelihood when planning treatment. Khan said. “For most patients, the disease is highly controllable, rather than curable.
Relapse is common and not a reflection of patient actions. Khan explained.
What Is the First Phase of Treatment for Multiple Myeloma?
The first phase, induction, has shifted from three-drug combinations (triplets) to four-drug combinations (quadruplets) for many, according to Dr. Khan.
One common four-drug combination is Dara-RVD, comprising:
- Daratumumab: A targeted antibody binding to a protein on myeloma cells
- Lenalidomide: Strengthens immune response to myeloma and slows cancer cell growth
- Bortezomib: Blocks myeloma cells from breaking down unwanted proteins
- Dexamethasone: A steroid destroying myeloma cells, reducing inflammation, and easing treatment side effects
Four-drug combinations are now standard. Khan noted.
The National Full Cancer Network (NCCN) is a group of leading cancer centers publishing widely followed treatment guidelines.
Initially, treatment focuses on reducing myeloma levels in the body, according to Dr. Rodriguez.
As symptoms like bone pain, fatigue, or anemia improve, patients often feel better. Regular appointments and blood tests monitor response and side effects.
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Rodriguez said, adding that severe nausea and vomiting are rare.
The care team may adjust medications or doses based on treatment effectiveness and tolerance.
Historically, an autologous stem cell transplant followed induction. This transplant uses the patient’s own stem cells. Today, effective non-transplant treatments make this step optional for many.
Khan said.
Transplants require substantial time and energy, with potential serious side effects. Suitability depends on overall health, fitness, disease characteristics, preferences, and other factors, not age alone.
Transplants can provide lasting disease control, especially for high-risk myeloma. Dr. Khan cited the DETERMINATION trial, which showed early transplants increased progression-free survival but not overall survival.
The NCCN recommends early consultation with a transplant team if considering this option and collecting stem cells within the first six treatment cycles.
Khan said.
- Eating nutritious foods
- Staying active
- Addressing dental issues and infections
- Arranging caregiver support
- Planning time away from work and daily activities
Before the transplant, patients receive high-dose chemotherapy, temporarily suppressing bone marrow.
Initial weeks may bring fatigue, nausea, appetite changes, low blood counts, and infection risk. As transplanted stem cells produce new blood cells, counts recover and energy gradually returns.
Most people improve over weeks or months, though recovery times vary.
Earlier Use of Advanced Immune Therapies
Immune-based treatments, once reserved for later stages, are now available earlier in the treatment process. CAR T-cell therapy and bispecific antibodies are two key types. CAR T-cell therapy modifies a patient’s immune cells to target and attack myeloma cells. Ciltacabtagene autoleucel (cilta-cel) may be used as early as the first relapse for those whose myeloma no longer responds to lenalidomide, provided they have received at least one prior therapy with a proteasome inhibitor and an immunomodulatory drug. Idecabtagene vicleucel (ide-cel) is another CAR T-cell option, used after at least two prior treatments, including an immunomodulatory drug, a proteasome inhibitor, and an anti-CD38 antibody.
Bispecific antibodies help immune cells connect to and destroy myeloma cells. Teclistamab, combined with daratumumab, may be used after at least one previous treatment. Teclistamab alone is also being considered as a second-line option. New treatments in development include additional CAR T-cell therapies, bispecific antibodies, and CELMoDs (cereblon E3 ligase modulatory drugs). At first relapse, patients and doctors may choose between CAR T-cell therapy, bispecific antibodies, or other multi-drug combinations based on factors like relapse timing, prior treatments, disease burden, blood cell counts, infection risk, treatment availability, and patient preferences.