Multiple Myeloma: Symptoms, Treatment & Living with Blood Cancer

What Is Multiple Myeloma?

Multiple myeloma is a cancer of plasma cells, a type of white blood cell that normally produces antibodies to fight infection. In myeloma, abnormal plasma cells multiply uncontrollably in the bone marrow, crowding out healthy blood cells and producing abnormal proteins that can damage bones, kidneys, and the immune system.

The bone marrow is the soft, spongy tissue inside bones where blood cells are made. Plasma cells are specialized white blood cells derived from B lymphocytes that normally produce antibodies (immunoglobulins) to help the body fight infections. When plasma cells become cancerous, they lose their ability to function normally and instead multiply out of control.

In multiple myeloma, these abnormal plasma cells (called myeloma cells) accumulate in the bone marrow and produce large quantities of an abnormal antibody called M-protein (monoclonal protein). This accumulation causes several problems: it crowds out the production of normal blood cells, leading to anemia, increased susceptibility to infections, and bleeding problems. The myeloma cells also release substances that activate bone-destroying cells (osteoclasts), leading to bone damage, pain, and fractures.

Multiple myeloma typically develops slowly and may not cause symptoms for years. Some people have a precursor condition called MGUS (monoclonal gammopathy of undetermined significance) or smoldering myeloma that may never progress to active disease. Understanding this spectrum of plasma cell disorders is important for appropriate monitoring and treatment timing.

How Cancer Develops in the Body

The human body consists of trillions of cells that normally grow, divide, and die in an orderly process. Sometimes mutations occur during cell division, which the body usually corrects or the abnormal cell is eliminated. However, when these repair mechanisms fail, increasingly abnormal cells can multiply with each division, eventually becoming cancer cells that grow uncontrollably and do not die when they should.

In myeloma, genetic mutations in plasma cells cause them to become malignant. Researchers have identified several chromosomal abnormalities and genetic mutations associated with myeloma, including translocations involving chromosome 14, deletions of chromosome 17p, and mutations in genes like RAS and TP53. These genetic changes help doctors predict how aggressive the disease may be and guide treatment decisions.

The Effects of Myeloma on the Body

Myeloma cells cause problems through several mechanisms that doctors remember using the acronym CRAB: Calcium elevation, Renal (kidney) insufficiency, Anemia, and Bone lesions. Understanding these effects helps explain the symptoms patients experience.

The myeloma cells crowd the bone marrow, pushing out normal blood cell production. This leads to fewer red blood cells (causing fatigue and shortness of breath), fewer white blood cells (increasing infection risk), and fewer platelets (causing easy bruising or bleeding). The abnormal plasma cells also release substances called cytokines that activate osteoclasts—cells that break down bone tissue. This leads to bone thinning, painful lesions, and fractures that may occur with minimal trauma.

The skeleton contains calcium, which is released into the bloodstream when bone is destroyed. Elevated calcium (hypercalcemia) can cause thirst, frequent urination, constipation, confusion, and kidney problems. The M-protein and light chains produced by myeloma cells can also directly damage the kidneys by clogging the tiny tubules that filter blood.

What Are the Symptoms of Multiple Myeloma?

The most common symptoms of multiple myeloma include persistent bone pain (especially in the back, ribs, and pelvis), unexplained fatigue, frequent infections, weight loss, excessive thirst, and numbness or weakness in the legs. Many patients have no symptoms initially, and the disease is discovered through routine blood tests.

Multiple myeloma often develops slowly over months or years, and many people have no symptoms when the disease is first detected. When symptoms do appear, they can vary considerably between individuals depending on which parts of the body are affected. The gradual onset of symptoms can make early recognition challenging, as many symptoms are common to other conditions.

Bone pain is the most common symptom of multiple myeloma, affecting approximately 70% of patients at diagnosis. The pain typically occurs in the back, ribs, and pelvis—areas with active bone marrow. Unlike muscle pain, which often improves with rest, myeloma bone pain tends to worsen with movement or physical exertion. The pain results from myeloma cells damaging bone tissue, which can lead to fractures even with minor stress or everyday activities.

Fatigue is another hallmark symptom, often resulting from anemia caused by myeloma cells crowding out red blood cell production. Patients may notice they tire easily during normal activities, feel weak, or experience shortness of breath with minimal exertion. This fatigue can significantly impact quality of life and ability to perform daily tasks.

When Myeloma Causes More Serious Symptoms

In some cases, myeloma can cause more severe symptoms requiring urgent medical attention. Spinal cord compression occurs when vertebrae weakened by myeloma collapse or when collections of myeloma cells (plasmacytomas) press on the spinal cord. This can cause sudden back pain, numbness, weakness in the legs, or loss of bladder or bowel control—symptoms that require immediate medical evaluation.

Hypercalcemia (elevated blood calcium) can cause confusion, extreme thirst, nausea, constipation, and in severe cases, cardiac arrhythmias or unconsciousness. Hyperviscosity syndrome occurs when the M-protein makes blood too thick, potentially causing vision problems, headaches, bleeding, or neurological symptoms. These complications, while less common, highlight the importance of regular monitoring once myeloma is diagnosed.

Symptoms That May Not Be Due to Myeloma

It's important to remember that these symptoms can have many causes other than myeloma. Back pain is extremely common and usually results from muscle strain, arthritis, or disc problems. Fatigue can result from poor sleep, stress, anemia from other causes, thyroid problems, or many other conditions. Frequent infections may simply indicate exposure to viruses or bacteria rather than an underlying blood disorder.

When Should You See a Doctor About Myeloma Symptoms?

See a doctor if you have persistent bone pain (especially in your back or ribs) that worsens with activity, unexplained fatigue that doesn't improve with rest, frequent infections, or symptoms of high calcium such as excessive thirst, confusion, or constipation. Many cases are discovered during routine blood tests before symptoms develop.

Because myeloma symptoms develop gradually and overlap with many common conditions, knowing when to seek evaluation can be challenging. However, certain patterns of symptoms warrant medical attention. Persistent bone pain that doesn't improve with standard treatments, especially if it worsens at night or with activity, should be evaluated. Similarly, fatigue that interferes with daily activities and doesn't improve with rest deserves investigation.

If you have unexplained weight loss, recurring infections (such as pneumonia more than once in a year), or symptoms suggestive of elevated calcium (extreme thirst, frequent urination, constipation, confusion), schedule an appointment with your healthcare provider. Blood tests can often identify abnormalities that suggest further evaluation is needed.

Many myeloma diagnoses begin with the incidental finding of elevated protein levels or abnormal kidney function on routine blood work. If your doctor mentions an M-spike, elevated total protein, or unexplained anemia, they may recommend additional testing to determine the cause. Early detection allows for monitoring and, when needed, earlier intervention.

How Is Multiple Myeloma Diagnosed?

Multiple myeloma is diagnosed through blood tests (serum protein electrophoresis, complete blood count, kidney function), urine tests (for Bence Jones protein), bone marrow biopsy (showing >10% plasma cells), and imaging studies (CT, MRI, or PET scan to identify bone lesions). The diagnosis requires meeting specific criteria established by the International Myeloma Working Group.

Diagnosing multiple myeloma involves a comprehensive evaluation using multiple tests. No single test confirms the diagnosis; instead, doctors look at the overall picture from blood work, urine analysis, bone marrow examination, and imaging studies. This thorough approach helps distinguish myeloma from precursor conditions and determines the extent of disease.

The diagnostic workup typically begins when routine blood tests reveal abnormalities or when symptoms prompt investigation. Your doctor may find elevated total protein, anemia, elevated creatinine (indicating kidney involvement), or elevated calcium. These findings trigger more specific testing to determine if myeloma is present.

Blood and Urine Tests

Serum protein electrophoresis (SPEP) separates blood proteins into groups and can identify the M-protein characteristic of myeloma. Immunofixation determines the specific type of M-protein present (IgG, IgA, or light chains). Serum free light chain assay measures kappa and lambda light chains, which can be elevated even when the full M-protein isn't detectable. These tests help quantify disease burden and monitor response to treatment.

Urine tests similarly analyze proteins excreted by the kidneys. Bence Jones protein refers to light chains that pass into urine and can indicate myeloma. A 24-hour urine collection with electrophoresis and immunofixation provides important information about the type and amount of abnormal protein production.

Bone Marrow Biopsy

A bone marrow biopsy is essential for diagnosing myeloma. This procedure, usually performed on the hip bone under local anesthesia, removes a small sample of bone marrow for examination. Pathologists look at the percentage and appearance of plasma cells, and genetic testing identifies chromosome abnormalities that affect prognosis and treatment decisions.

In healthy bone marrow, plasma cells make up less than 5% of cells. In active myeloma, plasma cells typically exceed 10% of bone marrow cells (often much higher) and show abnormal features under the microscope. Genetic tests like FISH (fluorescence in situ hybridization) identify high-risk features such as deletion 17p, t(4;14), and t(14;16) translocations.

Imaging Studies

Imaging helps identify bone lesions and their extent. Traditional X-rays can show "punched-out" lytic lesions characteristic of myeloma. However, modern guidelines recommend low-dose whole-body CT, MRI, or PET-CT as more sensitive methods for detecting bone involvement.

MRI is particularly useful for evaluating the spine and detecting lesions before they become visible on X-rays. PET-CT combines metabolic and anatomical imaging to identify active disease throughout the body. These imaging modalities help determine disease stage and guide treatment planning.

What Causes Multiple Myeloma?

The exact cause of multiple myeloma is unknown. Unlike some cancers, there are no clearly established modifiable risk factors. Known risk factors include older age, male sex, African American ancestry, personal history of MGUS, and family history of myeloma or related plasma cell disorders.

Scientists have not identified a definitive cause for multiple myeloma. The disease appears to result from a complex interplay of genetic factors, immune system changes, and possibly environmental exposures over time. Unlike cancers associated with smoking or specific infections, myeloma lacks clear preventable risk factors.

Research has identified several factors that increase myeloma risk, though having these risk factors doesn't mean someone will develop the disease. Age is the strongest risk factor—myeloma is rare before age 40 and most commonly diagnosed in people over 65. Men are slightly more likely to develop myeloma than women. African Americans have approximately twice the incidence of myeloma compared to Caucasians and often develop the disease at younger ages.

MGUS: A Precursor Condition

Almost all cases of multiple myeloma are preceded by a precursor condition called MGUS (monoclonal gammopathy of undetermined significance). MGUS is characterized by the presence of M-protein in the blood but without the organ damage or symptoms of myeloma. MGUS is common, affecting approximately 3% of people over 50, but only about 1% of MGUS cases per year progress to myeloma.

Smoldering myeloma represents an intermediate condition between MGUS and active myeloma. Patients have higher levels of M-protein and bone marrow plasma cells but no symptoms or organ damage. Smoldering myeloma has a higher progression risk (about 10% per year in the first five years), and some high-risk patients may benefit from early treatment.

Family History and Genetics

Having a first-degree relative (parent, sibling, or child) with myeloma slightly increases risk, but familial cases are uncommon. Most people with myeloma have no family history of the disease. Researchers are studying inherited genetic variants that may predispose to myeloma, but routine genetic screening of family members is not currently recommended.

How Is Multiple Myeloma Treated?

Multiple myeloma treatment typically involves combination drug therapy using proteasome inhibitors, immunomodulatory drugs, and corticosteroids. Eligible patients may receive high-dose chemotherapy followed by autologous stem cell transplant. Newer treatments include monoclonal antibodies, CAR-T cell therapy, and bispecific antibodies. Treatment is tailored to each patient's age, health, and disease characteristics.

Treatment for multiple myeloma has advanced dramatically over the past two decades, with numerous new drug classes transforming what was once a rapidly fatal disease into a chronic, manageable condition for many patients. The goal of treatment is to kill myeloma cells, achieve remission, prevent complications, and maintain quality of life.

Treatment decisions depend on many factors: whether the disease is causing symptoms (active myeloma requiring treatment vs. smoldering myeloma that may be monitored), the patient's age and overall health, the genetic features of the myeloma cells, and the patient's preferences and goals. For most patients with active myeloma, treatment begins promptly after diagnosis.

Initial (Induction) Therapy

Initial treatment typically combines drugs from different classes that attack myeloma cells through various mechanisms. Standard regimens often include a proteasome inhibitor (such as bortezomib or carfilzomib), an immunomodulatory drug (such as lenalidomide), and a corticosteroid (dexamethasone). Many regimens now also include a monoclonal antibody (such as daratumumab) for enhanced effectiveness.

Proteasome inhibitors work by blocking the proteasome, a cellular structure that myeloma cells depend on for survival. Without functional proteasomes, abnormal proteins accumulate inside the cell, triggering cell death. These drugs are highly effective and form the backbone of most myeloma treatment regimens.

Immunomodulatory drugs (IMiDs) work through multiple mechanisms: directly killing myeloma cells, boosting immune system recognition of cancer cells, and interfering with the bone marrow environment that supports myeloma growth. They're typically taken as oral capsules and require careful monitoring for side effects including blood clots and birth defects.

Monoclonal antibodies like daratumumab target specific proteins on myeloma cell surfaces (CD38), marking them for destruction by the immune system. These drugs have significantly improved outcomes when added to standard regimens and continue to be used in maintenance therapy for many patients.

Stem Cell Transplantation

For eligible patients (generally those under 70-75 in good health), autologous stem cell transplantation remains an important treatment that can deepen remission and extend disease-free periods. This procedure involves collecting the patient's own stem cells, administering high-dose chemotherapy (typically melphalan) to kill remaining myeloma cells, then returning the stem cells to regenerate the bone marrow.

Stem cell transplant is not curative, but it typically achieves deeper remission than drug therapy alone. Patients usually undergo transplant after initial induction therapy has reduced disease burden. Some patients may benefit from a second (tandem) transplant or may save collected stem cells for a later transplant at relapse.

Maintenance Therapy

After achieving remission, most patients continue treatment with lower-intensity "maintenance" therapy to prolong remission. Lenalidomide is the most commonly used maintenance drug, often continued until disease progression or intolerance. Some patients also receive proteasome inhibitor maintenance or combination maintenance regimens.

Newer and Emerging Treatments

CAR-T cell therapy represents a revolutionary approach in which the patient's own T cells are genetically modified to recognize and attack myeloma cells. Two CAR-T products (idecabtagene vicleucel and ciltacabtagene autoleucel) targeting BCMA are now approved for relapsed/refractory myeloma, offering new hope for patients whose disease has resisted multiple prior treatments.

Bispecific antibodies are another exciting development. These engineered proteins simultaneously bind to myeloma cells and T cells, bringing them together to trigger cancer cell destruction. Teclistamab and elranatamab are examples now available for relapsed myeloma, with more in development.

What Other Treatments May Be Needed?

Supportive care for myeloma includes bone-strengthening drugs (bisphosphonates or denosumab), treatment for anemia, infection prevention, pain management, and medications for kidney protection. Radiation therapy may be used for painful bone lesions or plasmacytomas. This comprehensive approach helps manage symptoms and prevent complications.

Treating multiple myeloma involves more than just anti-cancer drugs. Supportive care addresses the various complications and symptoms that arise from both the disease and its treatment. This comprehensive approach is essential for maintaining quality of life and preventing serious complications.

Bone-Strengthening Treatment

Bisphosphonates (such as zoledronic acid) or denosumab are given to nearly all myeloma patients to slow bone destruction and reduce the risk of fractures and bone pain. These medications inhibit osteoclasts—the cells that break down bone. Most patients receive monthly infusions for several years.

Before starting bisphosphonates, a dental examination is important because these drugs can rarely cause jaw problems (osteonecrosis of the jaw), especially after dental procedures. Good dental hygiene and preventive care help minimize this risk.

Treatment for Anemia

Anemia (low red blood cell count) is common in myeloma and can cause fatigue and shortness of breath. Treatment may include blood transfusions for severe anemia or erythropoietin-stimulating agents to boost red blood cell production. As myeloma treatment takes effect, anemia often improves naturally.

Infection Prevention and Treatment

Myeloma and its treatment impair the immune system, increasing infection risk. Preventive strategies may include vaccinations (such as pneumococcal and influenza vaccines), prophylactic antibiotics or antivirals during certain treatment phases, and intravenous immunoglobulin (IVIG) replacement for patients with recurrent infections.

Pain Management

Bone pain from myeloma can significantly impact quality of life. Management approaches include anti-myeloma treatment (which often improves pain as disease responds), pain medications (from acetaminophen to stronger opioids when needed), radiation therapy for localized painful lesions, and procedures like vertebroplasty for spinal fractures.

Radiation Therapy

While not a primary treatment for myeloma, radiation therapy effectively treats localized problems. It can quickly relieve pain from bone lesions, shrink plasmacytomas that compress nerves or the spinal cord, and treat isolated tumors. Radiation is usually given over several days and is well-tolerated by most patients.

What Happens After Treatment?

After initial treatment, most patients continue maintenance therapy while being monitored regularly with blood tests and sometimes imaging. Response categories range from complete response (no detectable disease) to progressive disease. Most patients eventually relapse and need additional treatment lines, but many achieve multiple remissions over years or decades.

Treatment completion in myeloma is different from many cancers. Rather than finishing treatment and returning for periodic surveillance, most myeloma patients continue some form of treatment (maintenance therapy) indefinitely while being monitored for disease response and progression.

Regular monitoring includes blood tests measuring M-protein levels, free light chains, blood counts, kidney function, and calcium. The frequency of testing depends on the clinical situation but typically occurs monthly to quarterly. Imaging may be repeated periodically or when symptoms suggest disease changes.

Understanding Treatment Response

Doctors classify treatment response using standard criteria. Complete response (CR) means no detectable M-protein and normalization of the bone marrow. Stringent complete response (sCR) adds normalization of free light chains. Very good partial response (VGPR) indicates >90% reduction in M-protein. Partial response (PR) indicates >50% reduction. Deeper responses generally correlate with longer remission.

Minimal residual disease (MRD) testing uses sensitive techniques to detect tiny amounts of remaining myeloma cells even when standard tests are negative. Achieving MRD negativity is associated with longer remission and is increasingly used to guide treatment decisions in clinical trials.

When Myeloma Relapses

Most patients with myeloma eventually experience disease progression (relapse), though the time to relapse varies greatly—from months to many years. Relapse treatment depends on many factors including how long remission lasted, what treatments were previously used, and the patient's current health.

Many effective treatments exist for relapsed myeloma, and patients often achieve multiple remissions throughout their disease course. Newer drugs like CAR-T cell therapy and bispecific antibodies have dramatically improved options for patients who have relapsed after multiple prior treatments.

What Is It Like Living with Multiple Myeloma?

Living with multiple myeloma means adapting to ongoing treatment and monitoring while maintaining quality of life. Most patients experience periods of remission when they feel well, alternating with periods requiring more intensive treatment. Physical activity, good nutrition, emotional support, and open communication with the healthcare team help patients thrive.

A myeloma diagnosis marks the beginning of a long-term relationship with the disease and the healthcare team. The disease course varies greatly between individuals—some live many years with minimal symptoms, while others face a more challenging course. Modern treatments have made it possible for most patients to maintain meaningful activities, relationships, and quality of life.

The psychological impact of a cancer diagnosis should not be underestimated. It's normal to experience anxiety, fear, anger, or depression. Support from family, friends, support groups, and mental health professionals can help process these emotions. Many patients find that after an initial adjustment period, they adapt to their "new normal" and find ways to live fully despite their diagnosis.

Physical Activity and Exercise

Physical activity is beneficial for myeloma patients, helping maintain bone strength, reduce fatigue, improve mood, and enhance overall well-being. Exercise recommendations should be individualized based on bone involvement and overall health. A physical therapist can help design a safe exercise program that accounts for any skeletal fragility.

Weight-bearing activities help maintain bone strength, while exercises to improve balance reduce fall risk (important given the risk of fractures). Even during intensive treatment, gentle movement and walking can help maintain function and reduce treatment-related fatigue.

Nutrition and Hydration

Eating a varied, balanced diet helps maintain strength and supports the immune system. Adequate protein is important for healing and maintaining muscle mass. Staying well-hydrated—drinking about 2-3 liters of fluids daily unless otherwise directed—helps protect the kidneys from damage by abnormal proteins.

Some patients experience nausea or appetite changes during treatment. Working with a dietitian can help address these challenges and ensure adequate nutrition. Certain dietary supplements may interact with myeloma treatments, so always discuss supplements with your oncology team.

Managing Fatigue

Fatigue is one of the most common and challenging symptoms for myeloma patients. While it has many causes (anemia, treatment effects, the disease itself, emotional factors), there are strategies to help manage it. Regular physical activity, paradoxically, often improves fatigue. Taking short rest periods rather than one long nap, maintaining consistent sleep schedules, and pacing activities can help conserve energy.

If fatigue is severe or worsening, notify your healthcare team. It may indicate anemia that could benefit from treatment, an infection, or other treatable cause. Understanding the cause helps guide the most effective management approach.

Relationships and Intimacy

Maintaining relationships remains important while living with myeloma. Partners and family members also need support as they adjust to their loved one's diagnosis. Open communication about feelings, fears, and needs helps maintain closeness and mutual support.

Sexual intimacy can continue, though treatment may affect desire and function. During periods when platelet counts are low, gentle activities that avoid skin trauma are advisable. Discussing concerns with your healthcare team can help address specific issues and find solutions.

Infection Prevention

Because myeloma and its treatment affect the immune system, taking precautions against infections is important. Good hand hygiene, avoiding crowds during cold and flu season, staying up-to-date on recommended vaccinations, and promptly reporting any signs of infection help minimize this risk. Most patients can maintain normal social activities while taking reasonable precautions.

What Is the Prognosis for Multiple Myeloma?

Multiple myeloma prognosis has improved dramatically with modern treatments. While overall 5-year survival is approximately 55-60%, many patients live much longer, especially those who respond well to treatment and are eligible for stem cell transplant. Prognosis varies based on disease stage, genetic features, kidney function, and treatment response.

Predicting individual outcomes in myeloma is challenging because the disease varies so much between patients. Some patients achieve long-lasting remissions measured in many years, while others have more aggressive disease that proves difficult to control. Understanding the factors that influence prognosis helps set realistic expectations and guide treatment decisions.

The Revised International Staging System (R-ISS) combines laboratory values (albumin, beta-2 microglobulin, LDH) with genetic features to classify patients into three prognostic groups. Stage I patients have the best prognosis, while Stage III patients face more challenging disease. However, even within risk categories, individual outcomes vary significantly.

Certain genetic abnormalities in myeloma cells, particularly deletion of chromosome 17p and translocations t(4;14) and t(14;16), are associated with more aggressive disease. However, newer treatments, including proteasome inhibitors and monoclonal antibodies, have improved outcomes even for patients with high-risk genetics.

Perhaps most importantly, myeloma treatment continues to improve. Clinical trials consistently introduce new drugs and approaches that benefit patients. The prognosis for someone diagnosed today is significantly better than it was even a decade ago, and ongoing research promises continued advances.

Where Can You Get Support?

Support for myeloma patients comes from the healthcare team (oncologist, nurses, social workers), patient advocacy organizations, support groups (in-person and online), mental health professionals, and family and friends. Financial assistance programs may help with treatment costs. Don't hesitate to ask for help—support improves outcomes and quality of life.

A cancer diagnosis affects not just the patient but entire families. Accessing support helps everyone cope with the challenges ahead. Your healthcare team includes not just doctors but nurses, social workers, and other professionals dedicated to helping you navigate the medical system and address practical concerns.

Patient advocacy organizations provide education, support groups, financial assistance resources, and connections to the myeloma community. Connecting with others who understand the myeloma experience can provide emotional support and practical advice.

Supporting Children in the Family

Children need age-appropriate information and support when a parent or grandparent has cancer. Being honest (without overwhelming detail), maintaining routines, and allowing children to express their feelings helps them cope. Many hospitals have child life specialists or social workers who can help guide these conversations.

Supporting Caregivers

Family members and friends who provide care also need support. Caregiving can be exhausting and emotionally draining. Support groups for caregivers, respite care, and help from others in the patient's support network can prevent caregiver burnout. Remember that taking care of yourself enables you to better care for your loved one.