Multiple Myeloma: NCCN Guidelines For Patients

NCCN Guidelines for Patients
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Version 1.2015
Multiple Myeloma
Available online at NCCN.org/patients
Introduction
Multiple Myeloma
Learning that you have cancer can be overwhelming. The goal of this book
is to help you get the best care. It explains which tests and treatments are
recommended by experts in multiple myeloma.
The National Comprehensive Cancer Network (NCCN) is a not-for-profit
alliance of 26 of the worlds leading cancer centers. Experts from NCCN have
written treatment guidelines for doctors who treat multiple myeloma. These
treatment guidelines suggest what the best practice is for cancer care. The
information in this patient book is based on the guidelines written for doctors.
This book focuses on the treatment of multiple myeloma. NCCN also offers
patient books on breast cancer, kidney cancer, melanoma, and many other
cancer types. Visit NCCN.org/patients for the full library of patient books as
well as other patient and caregiver resources.

Multiple Myeloma, Version 1.2015
Credits
About prostate cancer
Genetic counseling | Treatment
NCCN aims to improve the care given to patients with cancer. NCCN staff work with experts to create helpful programs and
resources for many stakeholders. Stakeholders include health providers, patients, businesses, and others. One resource is the
series of books for patients called the NCCN Guidelines for Patients. Each book presents the best practice for a type of cancer.
The patient books are based on clinical practice guidelines written for cancer doctors. These guidelines are called the NCCN
Clinical Practice Guidelines in Oncology (NCCN Guidelines). Clinical practice guidelines list the best health care options for
groups of patients. Many doctors use them to help plan cancer treatment for their patients. Panels of experts create the NCCN
Guidelines. Most of the experts are from NCCN Member Institutions. Panelists may include surgeons, radiation oncologists,
medical oncologists, and patient advocates. Recommendations in the NCCN Guidelines are based on clinical trials and the
experience of the panelists. The NCCN Guidelines are updated at least once a year. When funded, the patient books are updated
to reflect the most recent version of the NCCN Guidelines for doctors.
For more information about the NCCN Guidelines, visit NCCN.org/clinical.asp.
NCCN staff involved in making the guidelines for patients and doctors include:
NCCN Guidelines
NCCN Marketing
Dorothy A. Shead, MS, Director

Patient and Clinical Information Operations
Kristina M. Gregory, RN, MSN, OCN

Vice President/Clinical Information
Operations
Susan Kidney, Graphic Design Specialist
Rashmi Kumar, PhD, Senior Manager,

Clinical Content
Rachael Clarke, Medical Copyeditor
Laura J. Hanisch, PsyD, Medical Writer/

Patient Information Specialist
Lacey Marlow, Associate Medical Writer
NCCN Drugs & Biologics Programs
Endorsed by:
THE Leukemia & lymphoma society (LLS)
LLS is dedicated to developing better outcomes for blood cancer patients through research, education and patient
services and is happy to have this comprehensive resource available to patients with myeloma.
www.LLS.org/informationspecialists
Supported by NCCN Foundation
The NCCN Foundation supports the mission of the National Comprehensive Cancer Network (NCCN)
to improve the care of patients with cancer. One of its aims is to raise funds to create a library of books for
patients. Learn more about the NCCN Foundation at NCCN.org/foundation.
2015 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines for Patients and illustrations
herein may not be reproduced in any form for any purpose without the express written permission of NCCN.
National Comprehensive Cancer Network (NCCN)
275 Commerce Drive Suite 300
Fort Washington, PA 19034
215.690.0300

Contents
Multiple Myeloma
4
How to use this book
53 Part 5
About multiple myeloma

Explains the growth, spread, and
symptoms of multiple myeloma.
13 Part 2
63
Glossary:
74
NCCN Panel Members
75
NCCN Member Institutions
76
Index
Offers tips to help you talk with your

doctors and get a treatment plan that
meets all your needs.
64
Dictionary
71 Acronyms
Tests for myeloma
Describes the recommended tests to

confirm multiple myeloma and plan
treatment.
21 Part 3
Overview of myeloma
treatments
Describes the types of treatments for

multiple myeloma and the symptoms
caused by the cancer.
33 Part 4
Treatment guide
Presents the recommended course of

action from diagnosis to after myeloma
treatment.

Making treatment decisions
5 Part 1

How
to use this book
Making sense of medical

terms
Who should read this book?

This book is about treatment for multiple
myeloma, a type of cancer that starts in plasma
cells. Patients and those who support them
caregivers, family, and friendsmay find this
book helpful. It may help you talk with your
treatment team, understand what doctors say,
and prepare for treatment.
In this book, many medical words are included

that describe cancer, tests, and treatments.
These are words that you will likely hear from
your treatment team. Some of this information
may be new to you, and it may be a lot to learn.
Dont be discouraged as you read. Keep reading
and review the information. Be sure to ask your
treatment team to explain a word or phrase that
you dont understand.
Does the whole book

apply to me?
Words that you may not know are defined in the

text or in the Dictionary. Words in the Dictionary
are underlined when first used on a page.
Acronyms are defined in the text when first used
and are also defined in the Glossary. Acronyms
are words formed from the first letters of other
words. One example is CBC for complete blood
count.
This book includes important information for

many situations. Thus, you will likely not get
every test and treatment listed. Your treatment
team can point out what applies to you and give
you more information. As you read through this
book, you may find it helpful to make a list of
questions to ask your doctors.
The recommendations in this book are based
on science and the experience of NCCN
experts. However, each patient is unique and
these specific recommendations may not be
right for you. Your doctors may suggest other
tests or treatments based on your health and
other factors. This book does not replace the
knowledge and suggestions of your doctors.

3
1
About
Ductalmultiple
carcinoma
myeloma
in situ

1 About multiple
myeloma
What are plasma cells?
How does multiple myeloma start?
What are M-proteins?
10 Symptoms of multiple myeloma

12 Review
Learning that you have cancer can

be overwhelming and confusing.
Part 1 explains some basics about
multiple myeloma that may help
you better understand this disease.
These basics may also help you start
planning for treatment.
Blood is made of many types of cells, called blood

cells. The three main types of blood cells are
platelets, red blood cells, and white blood cells.
Each type of blood cell has a certain job in the body.
Platelets help control bleeding. Red blood cells carry
oxygen throughout the body. White blood cells (also
called immune cells) are part of the immune system
and help fight infections in the body.
Most blood cells are made in the bone marrow. Bone
marrow is the soft, sponge-like tissue found in the
center of most bones. See Figure 1.1. Blood cells are
made from special, immature cells called blood stem
cells. Blood stem cells can develop into all types of
mature blood cells.
Many types of white blood cells are made from a blood
stem cell. See Figure 1.2. Types of white blood cells
include granulocytes, B-cells, and T-cells. The types of
white blood cells fight germs in different ways. When
germs invade the body, B-cells change into plasma
cells. In a healthy person, less than 5 out of 100 cells
in the bone marrow are plasma cells.

Plasma cells make antibodies. Antibodies (also called

immunoglobulins) are proteins that help your body
find and kill germs. Each type of plasma cell makes
only one type of antibody, which is designed to attack
the specific germ that is causing the infection or
illness. There are five types of antibodies, and each
differs in how it fights germs. Without enough different
plasma cells to make all five types of antibodies in
response to germs, the body cant fight illnesses.
Plasma cells also play an important role in the

maintenance of bone health. They are part of the
repair process that keeps your bones healthy. Plasma
cells recognize weaknesses in your bones and
release hormones that recruit other cells to break
down damaged bone and make new bone to repair.
Figure 1.1
Blood cells in bone
marrow
Bone marrow is the
soft, sponge-like
tissue in the center
of most bones. Blood
stem cells in the bone
marrow make all types
of blood cells.
Illustration Copyright 2015 Nucleus Medical Media. All rights reserved. www.nucleusinc.com
Blood stem cell
Figure 1.2
Blood stem cells make
all types of blood cells
Blood stem cells are
immature cells from
which all types of
blood cells are made.
B-cells are a type of
white blood cells that
turn into plasma cells.
Red blood
cells
Platelets
Granulocytes
B-cell
Plasma cell

T-cell
How does multiple myeloma start?
How does multiple myeloma

start?
In contrast to plasma cells, myeloma cells make new

cells that arent needed and dont die quickly when
old or damaged. See Figure 1.3. The myeloma
cells continue to make more and more copies of
themselves. As a result, a group of myeloma cells
with the same gene mutation forms. A mass of
myeloma cells is called a plasmacytoma.
Multiple myeloma (also simply called myeloma) is a

cancer that starts in plasma cells. Plasma cells grow
and then divide to make new cells. New cells are
made as the body needs them. When plasma cells
grow old or get damaged, they die.
When there is only one mass of myeloma cells, it

is called a solitary plasmacytoma. Over time, the
myeloma cells can grow enough to spread throughout
the bone marrow. This is called multiple myeloma.
The myeloma cells can crowd out normal blood cells
in the bone marrow, invade bone tissue, and spread
all over the body.
Genes are the instructions in cells for making new

cells and controlling how cells behave. Changes in
their genes turn plasma cells into myeloma cells. An
abnormal change in a gene is called a gene mutation
or defect.
Figure 1.3
Plasma versus myeloma
cell growth
Normal plasma cells
divide to make new cells
as the body needs them.
Normal cells die once
they get old or damaged.
Myeloma cells make new
cells that arent needed
and dont die quickly
when old or damaged.

Heavy chains are one of five formsA, D, G, E, or

M. And light chains are one of two formskappa or
lambda. The form of heavy chain present defines the
type of antibody. Most people with myelomaabout
60 out of every 100have myeloma cells that make
G antibodies.
Like plasma cells, myeloma cells also make

antibodies. But, the antibodies made by myeloma
cells arent normal. They are all copies (clones)
of one type of antibody. Thus, these are called
monoclonal proteins or M-proteins. Myeloma cells
make M-proteins without control and not in response
to a specific germ in the body. M-proteins dont help
to fight infections.
As shown in Figure 1.4, myeloma cells also tend

to make more light chains than needed to form a
complete M-protein. These are called free light chains
because they arent attached to a heavy chain as
in a normal antibody. High levels of free light chains
are found in the urine of most people with myeloma
(75 out of every 100 people). In about 20 out of
100 people with myeloma, the myeloma cells only
make free light chains and no complete M-proteins.
Doctors call this light chain myeloma or Bence Jones
myeloma.
In most patients, myeloma cells make very large

amounts of M-proteins. Rarely, people with myeloma
make very little or no M-protein. This is called
oligosecretory or nonsecretory myeloma.
Normal antibodies are made of two heavy protein
chains and two light protein chains. See Figure 1.4.
Figure 1.4
Antibodies made by a
plasma cell versus a
myeloma cell
Antibodies are made of
2 heavy chains and 2
light chains. Myeloma
cells tend to make
more light chains than
needed to form an
antibody. These are
called free light chains.

About multiple myeloma Symptoms of multiple myeloma
Symptoms of multiple myeloma
stop bleeding by forming blood clots. Bruising or

bleeding easily is a symptom of having a low number
of platelets. Too many myeloma cells in the bone
marrow can crowd out platelets.
In a healthy person, there are plenty of normal blood

cells and all five types of antibodies. In a person with
myeloma, too few normal blood cells are made when
the bone marrow is full of myeloma cells. Likewise,
normal antibodies are outnumbered by the one
type of flawed antibodyM-proteinmade by the
myeloma cells. As a result, symptoms of the cancer
will appear. When myeloma is causing symptoms,
it is called active myeloma. When myeloma isnt
causing symptoms, it is called smoldering myeloma
or asymptomatic myeloma. Common symptoms of
active myeloma include:
Frequent infections and fevers
Fever is a sign that your body is trying to fight off an

infection. Frequent fever and infections is a symptom
of having too few white blood cells, but this can also
be due to low levels of normal antibodies. A low
number of white blood cells can result from too many
myeloma cells in the bone marrow.
Bone damage and pain
Myeloma cells can cause bone damage when they

crowd out normal cells in the bone marrow. They also
release (secrete) hormones that begin to break down
bone. Areas of bone damage are called bone lesions
and can be very painful. Bone lesions also weaken
bones so they may break (fracture) easily. Common
sites of bone damage from myeloma are the spine,
skull, hip bone, ribs, and shoulders. See Figure
1.5. The most common fracture site is in the bones
(vertebrae) of the spine. These fractures can be very
painful, but they can also occur without any pain.
Fatigue and feeling weak
Fatigue is severe tiredness despite getting enough

sleep. Fatigue and feeling weak are symptoms of
anemia. Anemia is a condition in which the number of
red blood cells is low. Anemia can be caused by too
many myeloma cells crowding out red blood cells in
the bone marrow.
Bruising or bleeding easily
Platelets are blood cells that help heal wounds and
Figure 1.5
Common areas of bone
damage by myeloma
Myeloma cells can
cause much damage to
bones. This can be very
painful and can cause
bones to break easily.
Common sites of bone
damage include the
ribs, skull, spine, and
hip bone.

10
About multiple myeloma Symptoms of multiple myeloma
Kidney problems
The kidneys are a pair of organs that filter blood

to remove waste, which leaves the body in urine.
Increased or decreased urine output is a symptom of
kidney damage. The high levels of M-proteins made
by the myeloma cells can cause kidney damage.
Myeloma can damage bones, and this bone damage
causes calcium to be released into the bloodstream.
Calcium is a mineral needed for healthy bones. But,
high levels of calcium in the bloodstream can damage
the kidneys.

11
Review
Review
Myeloma is a cancer of plasma cells.
When myeloma cells have spread throughout

the bone marrow, it is called multiple
myeloma.
Plasma cells make antibodies that help to fight

infections and play a key role in bone repair.
Smoldering myeloma doesnt cause

symptoms.
Myeloma cells make too many copies of

themselves.
Active myeloma causes symptoms by taking

over bone marrow and destroying bone.
Myeloma cells make abnormal antibodies

called M-proteins that dont help to fight
germs.
One mass of myeloma cells is called a solitary
plasmacytoma.

12
Tests for myeloma

13
2 Tests for myeloma

14
General health tests
15
Blood tests
16 Urine tests
17
Tissue tests
19 Imaging tests
20 Review
General health tests
Treatment planning starts with

testing. The tests used for myeloma
are described on the next pages.
This information can help you use
the Treatment guide in Part 4. It may
also help you know what to expect
during testing. Not every person with
myeloma will receive every test listed.
Medical history
Before and after cancer treatment, your doctor will

assess your medical history. Your medical history
includes any health events in your life and any
medications youve taken. This information may affect
which cancer treatment is best for you. It may help to
make a list of old and new medications while at home
to bring to your doctors office. Since some health
problems run in families, your doctor may want to ask
about the medical history of your blood relatives.
Physical exam
Doctors often give a physical exam along with taking

a medical history. A physical exam is a review of your
body for signs of disease. During this exam, your
doctor will listen to your lungs, heart, and intestines.
Parts of your body will likely be felt to see if organs
are of normal size, are soft or hard, or cause pain
when touched.

14
Tests for myeloma
Blood tests
Blood tests
Doctors test blood to look for signs of myeloma in
the bloodstream. Blood tests are done along with
other initial tests to help confirm (diagnose) myeloma.
Blood is made of red blood cells, white blood cells,
and platelets. It also has many proteins and other
chemicals. Different types of blood tests are used
to look for and measure different substances in the
blood. These tests help doctors learn more about the
myeloma and your health.
Some blood tests are used to assess the extent or
amount of myeloma in your body. This is referred to
as the tumor burden. Other tests are used to check
the health of your bones, kidneys, and other organs.
Blood tests may be repeated to check how well
cancer treatment is working and to check for side
effects.
For a blood test, your doctor will insert a needle into
your vein to remove a sample of blood. The blood
sample will then be sent to a lab for testing. The types
of blood tests used for myeloma are described next.
Tumor burden
SPEP. SPEP (serum protein electrophoresis) is
a test that measures the amount of M-proteins in

the blood. High levels may be a sign of advanced
myeloma.
SIFE. SIFE (serum immunofixation electrophoresis)
is a test that finds the type of M-proteins present in

the blood. It finds the type of M-proteins by showing
which form of heavy chains and light chains they
have.
Serum quantitative immunoglobulins. This test

measures the amount of each type of antibody in the
blood. It will show if the level of any type of antibody
is abnormaltoo high or too low.

Serum free light chain assay. This test measures

the number of free light chains in the blood. This
test is helpful when it isnt possible to measure the
amount of M-proteins with SPEP or in urine.
Beta-2 microglobulin. Beta-2 microglobulin is a

small protein made by many types of cells, including
myeloma cells. It is measured with a blood chemistry
test. High levels of this protein may be a sign of
advanced myeloma.
LDH. LDH (lactate dehydrogenase) is a protein
made by myeloma cells. It is measured with a blood

chemistry test. High levels of LDH may be a sign of
advanced myeloma.
Albumin. Albumin is the main protein in blood plasma

and is measured with a blood chemistry test. Low
levels of this protein may be a sign of advanced
myeloma.
Blood cells
CBC. A CBC (complete blood count) is a test that
measures the number of white blood cells, red blood

cells, and platelets. As myeloma cells take over the
bone marrow, too few normal blood cells are made.
HLA typing. HLAs (human leukocyte antigens) are
special proteins found on the surface of most cells in

the body. These proteins help the body to tell its own
cells apart from foreign cells. The unique set of HLA
proteins on a persons cells is called the HLA type.
HLA types differ among people just like blood types
differ among people. HLA typing is a blood test that
finds a persons HLA type. HLA typing is done before
treatment that transfers blood stem cells from another
person to the patient (see page 27). The patients
HLA type and the donors HLA type must be a nearperfect match for this treatment to work. This is
because the HLA type affects how the body responds
to foreign substances.
15
Tests for myeloma Urine tests
Urine tests
Bone and kidney health

Calcium. Calcium is a mineral that is found in many
Besides blood, doctors also test urine to look for

signs of disease. Urine tests can be used to confirm
(diagnose) myeloma, assess if organs are working
well, and check the results of cancer treatments.
Urine tests are also used to assess the tumor
burdenthe extent or amount of myeloma in your
body. The types of urine tests used for myeloma are
described next.
body tissues, but mostly in the bones. It is measured

with a blood chemistry test. High levels of calcium in
the blood may be a sign of myeloma destroying bone.
Creatinine. Creatinine is waste from muscles that

is filtered out of blood into urine by the kidneys. It is
measured with a blood chemistry test. High levels
of creatinine in the blood may be a sign of kidney
damage.
Tumor burden
UPEP. UPEP (urine protein electrophoresis) is a test
BUN. BUN (blood urea nitrogen) is a waste product
made by the liver and filtered out of blood into urine

by the kidneys. BUN is measured with a blood
chemistry test and high levels may be a sign of kidney
damage.
that measures the amount of M-proteins in the urine.

For this test, urine is collected for 24 hours and then
sent to a lab for testing.
Electrolytes. Electrolytes are minerals in the blood
a test that identifies the type of M-proteins present in

urine. Only light chains, not heavy chains, are found
in urine.
UIFE. UIFE (urine immunofixation electrophoresis) is
needed for organs to work well. They are measured

with a blood chemistry test. High levels of electrolytes
such as sodium, potassium, and calcium may be a
sign of kidney damage.
Total protein. Total protein is a test that measures

the amount and type of protein in urine. For this
test, urine is collected over a 24-hour period. Testing
24-hour urine for light chains (also called Bence
Jones protein) helps to measure the tumor burden in
patients with myeloma cells that mainly or only make
light chains.
Serum viscosity. Serum viscosity is a blood test that

measures the thickness of your blood. A large amount
of M-proteins in your blood can cause blood to
become very thicka condition called hyperviscosity.
This can damage your kidneys and other organs.
High levels of light chains in the urine can also cause
kidney damage.

16
Tests for myeloma
Tissue tests
Tissue tests
To confirm if you have cancer, a sample of tissue or
fluid must be removed from your body for testing. This
is called a biopsy. A biopsy is generally a safe test
and can often be done in about 30 minutes. The types
of biopsies used for myeloma are described below.
Bone marrow aspiration and biopsy
Bone marrow is the soft, sponge-like tissue in the

center of most bones where blood cells are made. A
bone marrow biopsy removes a small piece of solid
bone along with a small amount of soft bone marrow
inside the bone. A bone marrow aspiration removes
a small amount of liquid bone marrow from inside the
bone. Usually both tests are done at the same time
on the back of the hip bone.
These biopsies are done as outpatient teststhis

means you do not have to spend the night in the
hospital. First, you may be given a sedative injected
with a needle into your vein. Your doctor will then
clean the area of skin where the biopsy will be
performed. Next, you will receive local anesthesia to
numb the area of skin and bone beneath. After the
area is numbed, a hollow needle will be inserted into
your skin and then pushed into the bone to remove
the liquid bone marrow with a syringe. Then, a wider
needle will be inserted into the bone to remove the
solid bone and marrow sample. See Figure 2.1. You
may feel some pain while the samples are being
removed and your skin may be bruised afterward.
Figure 2.1
Bone marrow biopsy
Doctors use a bone
marrow biopsy and
aspiration to remove
a sample of bone
marrow for testing.
These tests are often
done at the same time
on the back of the hip
bone.

17
Tests for myeloma
Tissue tests
Tissue biopsy
Staining of marrow and fat pad for amyloid.
If you have a solitary plasmacytoma, a tissue biopsy

may be done to remove a sample of the mass for
testing. The sample is often removed with a needle.
This can be done with a fine-needle aspiration biopsy
or with a core needle biopsy. A fine-needle aspiration
biopsy uses a very thin needle to remove a small
sample from the mass. A core needle biopsy uses a
larger needle to collect a larger sample of tissue. For
a tissue biopsy, an imaging test may be used to guide
the needle through the skin and into the mass.
Amyloid is an abnormal protein found in people with

myeloma cells that make too many light chains.
Amyloid can collect and build up in tissues and
organs throughout the body. The buildup of amyloid,
called amyloidosis, can damage organs such as the
heart and kidneys. Tests for amyloid can be done on
a sample of bone marrow or the fat padfat from just
under the skin of the belly.
Flow cytometry. This is a test that measures the

amount of myeloma cells in the bone marrow. Doctors
use this test to judge the risk of progression to active
myeloma in patients without symptoms. A high
number of myeloma cells is a sign that the myeloma
will likely progress.
Lab tests
After the tissue samples are collected, they will be

sent to a lab for testing. A pathologist will examine
the samples with a microscope to look for myeloma
cells. The pathologist may also perform other tests
on the samples. It often takes several days before
the test results are known. The lab tests that may
be performed on the tissue samples are described
below.
Immunohistochemistry. This test is performed

on the bone marrow biopsy sample. It is used to
measure the number of myeloma cells in the bone
marrow.
Genetic tests. Genetic tests are used to check
Plasma cell labeling index. This test shows what
for abnormal genes. These tests are done in three

parts. Bone marrow cells are grown to make the cells
divide. Next, the dividing cells can be examined by
karyotyping. Karyotyping looks at a map (karyotype)
of the chromosomes in the myeloma cells. Myeloma
cells can also be examined with a test called FISH
(fluorescence in situ hybridization). FISH uses probes
that attach to certain parts of the chromosomes
known to be affected in myeloma. The newest testing
looks for certain genes that may be turned on or
turned off in myeloma cells.
percentage of the myeloma cells are dividing and how

fast they are doing it. Cells that are dividing quickly
are a sign of cancer that will spread fast.

18
Tests for myeloma Imaging tests
Imaging tests
Imaging tests take pictures (images) of the inside of
your body. These tests are often easy to undergo.
Before the test, you may be asked to stop eating or
drinking for several hours. You should also remove
any metal objects that are on your body. Some
imaging tests may use a contrast dye to make the
pictures clearer. This contrast dye can cause more
damage to frail kidneys. Thus, it should not be used in
patients with multiple myeloma. The types of imaging
tests used for multiple myeloma are described below.
PET scan
A PET (positron emission tomography) scan shows

how your cells are using a simple form of sugar. To
create pictures, a sugar radiotracer first needs to
be put into your body. The radiotracer emits a small
amount of energy that is detected by the machine that
takes pictures. Myeloma cells appear brighter in the
pictures because they use sugar more quickly than
normal cells. A PET scan is very good at showing
active myeloma and how far it has spread. PET is
often used with CT. PET/CT may be used when a
bone survey doesnt show any problems.
Bone survey
Figure 2.2 CT scan machine
A bone surveyalso called a skeletal surveyis a

test that uses a set of x-rays to take pictures of your
entire skeleton. A bone survey is done to check for
broken or damaged bones caused by myeloma.
A CT machine is large and has a tunnel in the

middle. During the test, you will lie on a table that
moves slowly through the tunnel.
Bone densitometry
Bone densitometry uses x-rays to make pictures that

show how strong or thin bones are. This test may be
used to decide if you need bisphosphonatesdrugs
that help to strengthen bones.
CT scan
A CT (computed tomography) scan takes many

pictures of a body part from different angles using
x-rays. See Figure 2.2. A computer combines all the
pictures to make one clear picture. A CT scan may be
given to further check for bone damage when a bone
survey doesnt show any problems.
MRI scan
An MRI (magnetic resonance imaging) scan uses

radio waves and powerful magnets to take pictures of
the inside of the body. It makes very clear pictures of
bone and may show if any bone has been damaged
by myeloma. An MRI scan may be given when the
bone survey doesnt show any problems.

19
Tests for myeloma
Review
Review
Cancer tests are used to plan treatment and
check how well treatment is working.
Tests of tissue or fluid from the bone marrow

are used to confirm myeloma.
Your health history and a body exam inform

your doctor about your health.
Tests that take pictures of the inside of your

body may show bone damage from the
cancer.
Blood and urine tests check for signs of

disease.

20
Overview of
myeloma treatments

21
3 Overview of
myeloma treatments
22
Radiation therapy
23 Surgery
23
Targeted therapy
24 Chemotherapy
24 Steroids
26 Stem cell transplant
28
Adjunctive treatment and

supportive care
30
Clinical trials
32 Review
Part 3 describes the main types of

treatments for multiple myeloma
and its symptoms. This information
may help you use the Treatment
guide in Part 4. It may also help
you know what to expect during
treatment. Radiation therapy and
surgery are types of local therapy,
which treats cancer cells in only one
part of the body. Targeted therapy,
chemotherapy, and steroids are types
of systemic therapy, which treats
cancer cells throughout the body.
Not every person with myeloma will
receive every treatment listed.

Radiation therapy
Radiation therapy is a type of local therapy. Local
therapy treats cancer cells in one small, specific
area of the body only. Thus, radiation therapy is
only used to treat solitary plasmacytomas. A solitary
plasmacytoma is a single mass of myeloma cells.
Radiation therapy uses high-energy rays to treat
cancer. The rays damage the genes in cells. This
either kills the cancer cells or stops new cancer cells
from being made. EBRT (external beam radiation
therapy) is the most common type of radiation
therapy used to treat solitary plasmacytomas. For
EBRT, a machine outside the body delivers radiation
to the cancer site. But, the radiation may also damage
normal cells.
22
Overview of myeloma treatments Surgery | Targeted therapy
Side effects of radiation therapy
A side effect is an unhealthy or unpleasant physical or

emotional condition caused by treatment. Side effects
of radiation therapy may not occur in the first few
visits. Over time, you may have nausea, diarrhea, and
fatigue. Other common side effects are changes in
your skin and hair loss in the treated area.
Surgery
Surgery is an operation to remove or repair a body
part. It is a type of local therapy. Surgery is rarely
used as a treatment for myeloma. It is only used to
remove a solitary plasmacytoma located outside of
the bone. Radiation therapy is often given before or
after the surgery. Surgery may also be used to fix
fractures in bones caused by myeloma.
Side effects of surgery
You may experience weakness, tiredness, and pain

after the surgery. Other common side effects are
swelling, surgical scars, and, less frequently, infections.
Targeted therapy
Targeted therapy is treatment with drugs that target
a specific or unique feature of cancer cells. Targeted
therapy is less likely to harm normal cells than
chemotherapy. Targeted therapy drugs treat myeloma
in a few different ways. Some block the growth of new
blood vessels that feed myeloma cells in the bone
marrow. Others block the action of groups of proteins
(proteasomes) that help the myeloma cells grow and
survive. An immunomodulator is a type of targeted
therapy that helps the immune system find and attack
Order of treatments
Most people with myeloma will receive more than one type of treatment. When and why treatments
are given can be hard to understand. Part 4 gives full details. Here, the terms that describe the order
of treatments are explained.
Primary
treatment
The main treatment

given to rid the body
of cancer.

Maintenance
treatment
Treatment given to
keep cancer away
after the primary or
previous treatment
worked well.
23
Additional
treatment
Treatment given
after previous
treatments failed to
kill all of the cancer
or keep it away.
Overview of myeloma treatments Chemotherapy | Steroids
cancer cells. See Chart 3.1 for a list of the targeted

therapy drugs and other drugs that are used to treat
myeloma.
Chemotherapy is given in cycles. A cycle includes

days of treatment followed by days of rest. Giving
chemotherapy in cycles lets the body have a chance
to rest before the next treatment. The cycles vary in
length depending on which drugs are used. Often,
the cycles are 14, 21, or 28 days long. Most of the
chemotherapy drugs listed in Chart 3.1 are liquids
that are slowly injected into a vein. Some are a pill
that is swallowed. The drugs travel in the bloodstream
to treat cancer throughout the body.
Side effects of targeted therapy
A side effect is an unhealthy or unpleasant physical

or emotional condition caused by treatment. Each
treatment for myeloma can cause side effects. How
your body will respond cant be fully known. Some
people have many side effects. Others have few.
Some side effects can be very serious while others
can be unpleasant but not serious.
Side effects of chemotherapy
Like targeted therapy, the side effects of

chemotherapy depend on many factors. This includes
the drug, the dose, and the person. In general, side
effects are caused by the death of fast-growing cells,
which are found in the intestines, mouth, and blood.
As a result, common side effects include low blood
cell counts, infections, diarrhea, nausea, vomiting,
mouth sores, tiredness or weakness, numbness or
tingling of hands or feet, skin and nail changes, hair
loss, swelling, and not feeling hungry.
The side effects of targeted therapy depend on the

drug and dose. Some of the side effects listed are
caused by only one targeted drug. Others are caused
by many targeted drugs but differ in how likely they
are to occur. Some common side effects of targeted
therapy drugs are tiredness, weakness, nausea or
vomiting, diarrhea, constipation, low red blood cell
count (anemia), low white blood cell count (can
increase risk of infection), low platelet count (can
increase risk of bruising and bleeding), blood clots,
numbness or tingling in the hands or feet, skin rash,
and muscle aches.
Steroids
Steroids are a type of drug used to relieve swelling
and inflammation, but some steroids have anti-cancer
effects. Steroids are often used in the treatment
of myeloma. Steroids can be used alone to treat
myeloma or used with chemotherapy, targeted
therapy, or both. See Chart 3.1 for a list of steroids
used to treat myeloma.
Chemotherapy
Chemotherapy is the use of drugs to kill cancer cells.
Many people refer to this treatment as chemo.
Chemotherapy drugs kill fast-growing cells throughout
the body, including cancer cells and normal cells.
Some chemotherapy drugs can also cause much
damage to your bone marrow.
Side effects of steroids
Most side effects of steroids go away over time once

the drugs are stopped. Some common side effects
are feeling hungry, trouble sleeping, slow wound
healing, upset stomach, and swelling in the ankles,
feet, and hands.
Different types of chemotherapy drugs attack cancer

cells in different ways. Thus, more than one drug
is often used. A combination regimen is the use of
two or more drugs. When only one drug is used, it is
called a single agent.

24
Overview of myeloma treatments Chemotherapy | Steroids
Chart 3.1 Drug treatments for multiple myeloma

Generic name
Brand name (sold as)
Type of drug
Bendamustine
Treanda
Chemotherapy
Bortezomib
Velcade
Targeted therapy
Carfilzomib
Kyprolis
Targeted therapy
Cisplatin
Platinol
Chemotherapy
Cyclophosphamide
Cytoxan
Chemotherapy
Dexamethasone
Decadron
Steroid
Doxorubicin
Adriamycin
Chemotherapy
Etoposide
VePesid
Chemotherapy
Interferon
Immunomodulator
Lenalidomide
Revlimid
Immunomodulator
Lipsomal doxorubicin
Doxil
Chemotherapy
Melphalan
Alkeran
Chemotherapy
Panobinostat
Farydak
Targeted therapy
Pomalidomide
Pomalyst
Immunomodulator
Prednisone
Steroid
Thalidomide
Thalomid
Immunomodulator
Vincristine
Oncovin
Chemotherapy
Vorinostat
Zolinza
Targeted therapy

25
Overview of myeloma treatments Stem cell transplant
Stem cell transplant
rarely, the breastbone) to draw out the bone marrow.

The needle must be inserted many times into one
or more spots in the bone to collect enough bone
marrow. The bone marrow will then be processed
to collect the stem cells. The stem cells will be
cryopreserved until the transplant. Collection of the
bone marrow takes about 1 hour and will likely cause
some pain and soreness for a few days afterward.
Other side effects, related to the anesthesia, may
include nausea, headache, and tiredness.
A stem cell transplant is a treatment that uses high

doses of chemotherapy to destroy diseased and
normal cells in the bone marrow and then replaces
them with healthy blood stem cells. The transplanted
stem cells should make new bone marrow. The steps
of treatment with a stem cell transplant are described
on the next pages.
Collecting the stem cells
High-dose chemotherapy
The first step of a stem cell transplant is to collect, or

harvest, the blood stem cells. Blood stem cells are
found in the bone marrow and in the bloodstream.
The stem cells can be collected from you or from
another person, called a donor. Your doctor will likely
collect enough stem cells from you for two transplant
procedures.
After the stem cells have been harvested, high doses

of chemotherapy are given to destroy any remaining
myeloma cells in your bone marrow. The high-dose
chemotherapy also destroys normal cells in the bone
marrow, including plasma cells and blood stem cells.
This greatly weakens your immune system so that
your body doesnt kill the transplanted stem cells.
However, not every person can tolerate the high-dose
chemotherapy before the transplant.
For myeloma treatment, stem cells are usually

collected from circulating blood in the bloodstream.
With this method, the first step is to remove blood
from a large vein in the arm using a central venous
catheter. The blood is then filtered through a machine
that removes the stem cells and returns the rest of
the blood to you, or the donor, through the catheter.
This process is called apheresis. Next, the harvested
cells are combined with a preservative, frozen, and
stored to keep them alive until they are transplanted
into you. This process is called cryopreservation.
Apheresis typically takes 4 to 6 hours and does
not require anesthesia. It usually causes only mild
discomfort such as lightheadedness, chills, numbness
around the lips, and cramping in the hands during the
procedure.
Blood stem cells can also be collected from your
bone marrow using bone marrow aspirations. In
this procedure, you will be given either regional
anesthesia or general anesthesia. Next, a needle will
be inserted through your skin into your hip bone (or,

26
Overview of myeloma treatments Stem cell transplant
Types of stem cell transplants

Autologous stem cell transplant
This type of transplant uses your own stem cells that are collected after
primary treatment. Autologous stem cell transplant is the most common type
of transplant used for active myeloma. But, it is not considered a cure because
the myeloma may come back even after long periods of disease control.
Tandem stem cell transplant

This is a type of autologous transplant. A tandem stem cell transplant is when
a planned second round of high-dose chemotherapy and a second autologous
stem cell transplant are given. These treatments are done within 6 months
after the first transplant.
Allogeneic stem cell transplant

This type of transplant uses stem cells collected from another person, called a
donor. Before the transplant, HLA typing is needed to check if you and the donor
are a good match. See page 15 for details on HLA typing.
This transplant may provide the best chance to cure myeloma, although
chances are low. A cure may be possible because the donors healthy stem
cells create a new immune system for your body. This transplant also causes
the GVT (graft-versus-tumor) effect. The GVT effect is when the transplanted
stem cells see the myeloma cells in your body as foreign and attack them.
Allogeneic stem cell transplants arent used very often for three reasons. First,
its hard to find a matching donor. Second, side effects are serious and include
death. Third, the risk of the myeloma coming back is still high.
Mini transplant
This is a type of allogeneic transplant. It is called a mini transplant because
lower doses of chemotherapy, radiation therapy, or both are given before the
transplant. The purpose of a mini transplant is to reduce the severity of side
effects but still have the GVT effect.
Donor lymphocyte infusion

A donor lymphocyte infusion is a procedure in which the patient receives
lymphocytes from the same person who donated stem cells for the allogeneic
transplant. A lymphocyte is a type of white blood cell that helps the body fight
infections. The purpose of a donor lymphocyte infusion is to stimulate the GVT
effect. This treatment may be used if the myeloma comes back after the first
allogeneic stem cell transplant.

27
Overview of myeloma treatments Adjunctive treatment and supportive care
Adjunctive treatment and

supportive care
Transplanting the stem cells
Once the high-dose chemotherapy is complete, the

harvested blood stem cells are put into your body
with a transfusion. A transfusion is when you receive
whole blood or parts of blood put directly into your
bloodstream through a vein. This process can take 1
to 5 hours to complete.
Adjunctive treatment is another treatment given at the

same time as the main (primary) cancer treatment.
It is given to assist the main treatment, such as
by improving its safety or how well it works. For
myeloma, adjunctive treatment includes supportive
care to manage the symptoms of myeloma and side
effects of myeloma treatment. It is an important part
of overall myeloma treatment. Some of the ways to
treat the health problems caused by myeloma and
myeloma treatment are described on the next pages.
The transplanted stem cells then travel to your bone

marrow and grow to make new healthy blood cells.
This is called engraftment and it usually occurs about
2 to 4 weeks after the transplant. Until then you have
little or no immune defense and so you are at high
risk for infection and bleeding. Therefore, you likely
will need to stay in a hospital in a very clean (sterile)
unit for about 2 weeks. You may be given antibiotic
drugs to prevent or treat infection. You may also be
given blood transfusions to prevent bleeding and
to treat anemia. It may take a few weeks or months
for blood cells to fully recover so that your immune
system is back to normal.
Bone damage
Multiple myeloma often weakens and destroys

bones. This can lead to problems such as bone
pain, bone fractures, and compression of the spine.
Drugs called bisphosphonates can help strengthen
bones and reduce the risk of bone problems such
as bone fractures. Thus, bisphosphonates are
recommended for all patients receiving primary
treatment for myeloma. But, these drugs can also
cause side effects such as osteonecrosis of the jaw.
Bisphosphonates are given as a liquid that is injected
into a veincalled an IV (intravenous) injection.
Side effects of stem cell transplants
Side effects can occur at each step of treatment with

a stem cell transplant. You may feel dizzy or have
tingling in your hands and feet during apheresis.
Common side effects of chemotherapy are listed on
page 24. While waiting for the cells to engraft, you will
likely feel tired and weak.
You may be referred to an orthopedic surgeon to

help prevent or treat a bone fracture. Surgeons can
prevent bone fractures by placing a splint to support
the bone and hold it in place. Surgery may be used
to treat fractures in the bones of the spinecalled
vertebrae. Two similar procedures that may be used
are vertebroplasty and kyphoplasty.
Allogeneic stem cell transplants have a high risk of

GVHD (graft-versus-host disease). GVHD is when
the donated cells (the graft) see the cells in your body
(the host) as foreign and attack them. The parts of
the body most commonly damaged by GVHD include
the skin, liver, and intestines. GVHD is a serious side
effect that can cause the transplant to fail by stopping
the donated stem cells from growing in your bone
marrow. GVHD can develop within a few weeks after
the transplant or much later.

Vertebroplasty is used to treat compression fractures

in the bones of the spine. A compression fracture is a
break in a bone caused by the collapse of bones in the
spine. This surgery involves injecting a type of cement
into the bones. The cement supports and strengthens
the bones for pain relief and to hold them in place.
28
Overview of myeloma treatments Adjunctive treatment and supportive care
With kyphoplasty, a balloon-like device is placed

in the fractured vertebrae and then inflated. This
spreads out the vertebrae to restore the normal shape
and height of the spine. Then the balloon is removed
and a type of cement is injected to support the
vertebrae and hold them in place.
Bone damage can be painful. Radiation therapy can
be used to treat this pain. It is very helpful for large
bone lesions that may cause bone fractures.
Kidney damage
Bone death causes calcium to be released into the

bloodstream. A high level of calcium in the blood is
dangerous for the kidneys. If this happens, you will
be treated with IV fluids and other drugs to help your
kidneys flush out the calcium.
Very high levels of M-proteins can cause the blood to
become very thicka condition called hyperviscosity.
This can damage the kidneys and other organs.
Blood thickness can be treated by filtering blood
through a machine to remove M-proteins. This
treatment is called plasmapheresis.
High levels of light chains can also damage the
kidneys. Free light chains combine with another
protein in the kidneys, which causes them to be too
large to pass through. The damage caused by this
blockage is called myeloma kidney. Prompt treatment
of myeloma is required to prevent permanent kidney
damage.
Infections
Myeloma and certain myeloma treatments can

increase the risk of infection. The risk of infection
can be reduced with vaccines for pneumonia, the flu,
and shingles. Shingles is an infection that causes a
painful skin rash and it is a side effect of bortezomib
and carfilzomib. Intravenous immunoglobulins may be
given to treat frequent, serious infections.
Blood clots
Some drugs, specifically thalidomide and

lenalidomide, can cause serious blood clots. If these
drugs are used, then adjunctive treatment with
blood thinners may be needed. Blood thinners are
medications that thin out the blood to reduce the risk
of blood clots.
Anemia
Myeloma cells may crowd out the normal blood cells

in the bone marrow. This can cause anemiaa
condition in which the number of red blood cells is
too low. Anemia can be treated with a drug called
erythropoietin. Erythropoietin stimulates the bone
marrow to make more red blood cells.

29
Overview of myeloma treatments Clinical trials
Clinical trials
New tests and treatments arent offered to the public
as soon as theyre made. They need to be studied
first. New uses of tests and treatments also need to
be studied.
A clinical trial is a type of research that studies a test
or treatment. Clinical trials study how safe and helpful
tests and treatments are. When found to be safe
and helpful, they may become tomorrows standard
of care. Because of clinical trials, the tests and
treatments in this book are now widely used to help
patients.
Tests and treatments go through a series of clinical
trials to make sure theyre safe and work. Without
clinical trials, theres no way to know if a test or
treatment is safe or helpful. Clinical trials are done in
a series of steps, called phases. The four phases of
clinical trials are described next using the example of
a new drug treatment:
Joining a clinical trial has benefits. First, youll have

access to the most current cancer care. Second, you
will receive the best management of care. Third, the
results of your treatmentboth good and badwill be
carefully tracked. Fourth, you may help other patients
with cancer.
Phase I trials aim to find the best dose and

way to give a new drug with the fewest side
effects. If a drug is found to be safe, it will be
studied in a phase II trial.
Phase II trials assess if a drug works for
a specific type of cancer. They are done in
larger groups of patients with the same type of
cancer.
Phase III trials compare a new drug to the
standard treatment. These are randomized,
meaning patients are put in a treatment group
by chance.
Phase IV trials test new drugs approved by
the FDA (U.S. Food and Drug Administration)
to learn about short-term side effects, longterm side effects, and safety. They involve
many patients with different types of cancer.

Clinical trials have risks, too. Like any test or

treatment, there may be side effects. Also, new
tests or treatments may not work better than current
treatments. Another downside may be that paperwork
or more trips to the hospital may be needed.
To join a clinical trial, you must meet the conditions
of the study. Patients in a clinical trial often have a
similar cancer type and general health. This helps
ensure that any response is because of the treatment
and not because of differences between patients. You
also must review and sign a paper called an informed
consent form to join a clinical trial. This form describes
the study in detail, including the risks and benefits.
Ask your treatment team if there is an open clinical
trial that you can join. There may be clinical trials
where youre getting treatment or at other treatment
centers nearby.
30
Overview of myeloma treatments Notes
My notes

31
Overview of myeloma treatments Review
Review
Surgery and radiation therapy are used when
there is a single mass of myeloma cells
called a solitary plasmacytoma.
An autologous stem cell transplant uses your

own stem cells.
An allogeneic stem cell transplant uses stem
cells from another person, called a donor.
Systemic therapy is the use of drugs to kill

myeloma cells throughout the body.
Chemotherapy drugs kill fast-growing cells,
including cancer cells and normal cells.
Adjunctive treatment for the symptoms

of myeloma and side effects of myeloma
treatment is very important.
Targeted therapy drugs target a specific or

unique feature of cancer cells.
A clinical trial studies a test or treatment to

see how safe it is and how well it works.
A stem cell transplant replaces damaged or

diseased bone marrow with healthy blood
stem cells.

32
About prostate cancer
Treatment guide

33
4 Treatment guide
36
4.1 Multiple myeloma testing

Presents the first set of tests that are
recommended to confirm multiple
myeloma and plan treatment.
38
4.2 Solitary plasmacytoma
Presents the recommended treatments for

a single mass of myeloma cells.
40
4.3 Smoldering multiple myeloma
Presents the recommended treatments

for multiple myeloma that isnt causing
symptoms.
42
4.4 Active multiple myeloma

Presents the recommended treatments
for multiple myeloma that is causing
symptoms.

34
Treatment guide
Part 4 is a guide through the

treatment options for people
with multiple myeloma. It shows
which tests and treatments are
recommended under which
conditions. This information is
taken from the treatment guidelines
written by NCCN experts for multiple
myeloma doctors.
Much effort has been made to make this guide easy

to read. Charts list the treatment options and map the
steps through the treatment process. The text along
with each chart explains the information presented
in the chart. Some words that you may not know are
defined on the page and in the Dictionary on page 64.
Words defined in the Dictionary are underlined when
first used on a page. More information about the tests
and treatments in this guide can be found in Parts 2
and 3.

35
Treatment guide
Multiple myeloma testing
4.1 Multiple myeloma testing

Chart 4.1 Tests for multiple myeloma
Initial tests for diagnosis
Possible other tests
Medical history and physical exam

Bone survey
CBC
Blood chemistry tests: BUN, creatinine, electrolytes,
LDH, albumin, calcium, beta-2 microglobulin
Serum free light chain assay
Serum quantitative immunoglobulins
SPEP and SIFE
24-hour urine for total protein
UPEP and UIFE
Immunohistochemistry and/or flow cytometry
Genetic tests
MRI scan
CT scan without contrast
PET/CT scan
Bone densitometry
Tissue biopsy for solitary plasmacytoma
Staining of marrow and fat pad for
amyloid protein
Plasma cell labeling index
Serum viscosity
HLA typing
Chart 4.1 shows the initial tests that are
also used to assess for symptoms of myeloma. A

CBC will show if the number of blood cells is low for
each blood cell type. A blood chemistry test checks
if certain substances in your blood are too low or too
high. This test is used to measure BUN, electrolytes,
and creatinine levels to check if your kidneys are
working well. It is used to measure calcium levels
to check for bone damage. It also measures LDH,
albumin, and beta-2 microglobulin to assess the
extent or severity of myeloma.
recommended when your doctor thinks you may have

multiple myeloma. These tests are used to confirm
(diagnose) myeloma and to assess if the cancer is
causing symptoms. For full details on each test, see
Part 2 on page 14.
The first list of tests in the chart above includes the
initial tests that are recommended for everyone. The
second list includes the tests that may be useful for
some people, in addition to the first set of tests.
The other blood tests and the urine tests are used
to check for and measure M-proteins. Very often,
the serum free light chain assay along with SPEP
and SIFE can detect multiple myeloma correctly
when it is present. The serum free light chain assay
is also useful for cancer prognosis and follow-up of
amyloidosis and oligosecretory myeloma.
Initial tests for diagnosis

The medical history and physical exam help your
doctors assess if youre having myeloma symptoms,
such as fatigue or bruising. A bone survey may show
if theres any bone damage. Some blood tests are

36
Treatment guide
Multiple myeloma testing
A bone marrow aspiration and bone marrow biopsy

are recommended to confirm (diagnose) multiple
myeloma. Immunohistochemistry shows if M-proteins
are present in the bone marrow. Flow cytometry
counts the number of myeloma cells present. Genetic
tests of bone marrow can find changes in genes
linked to myeloma. Genetic tests may show if genes
from two cells have been switched, if genes are
missing, or if too many copies of a gene have been
made.
A serum viscosity test is done to assess for increased

blood thickness, a condition called hyperviscosity.
HLA typing is needed if you will have treatment with
an allogeneic stem cell transplant. (See Part 2 on
page 14 for more test details.)
Possible other tests
For a solitary plasmacytoma, see

Chart 4.2 on page 38 for treatment
recommendations. For multiple
myeloma that is not causing
symptomscalled smoldering
myelomasee Chart 4.3 on page
40 for treatment recommendations.
For multiple myeloma that is causing
symptomscalled active myeloma
see Chart 4.4.1 on page 42 for
treatment recommendations.
In addition to the initial tests described above, a few

more tests may be useful for some people. An MRI
scan, CT scan, or PET/CT scan may be used to view
areas of your body where symptoms are present.
These imaging tests may show cancer or show if you
have bone damage. Bone densitometry can be used
to assess bone strength to see if you need drugs that
prevent or treat bone damage.
If imaging tests show a solitary plasmacytoma, it
must be confirmed with a tissue biopsy. Staining of
the bone marrow and fat pad is used to check for a
protein called amyloid. It is an abnormal protein found
in people with myeloma cells that make too many
light chains. Plasma cell labeling index is a test that is
used to assess how fast myeloma cells are dividing.

Next steps:
37
Treatment guide Solitary plasmacytoma
4.2 Solitary plasmacytoma

Chart 4.2 Primary treatment and follow-up for solitary plasmacytoma
Cancer type
Solitary osseous
plasmacytoma
Primary treatment
Follow-up tests
Radiation therapy
Radiation therapy,
Solitary
extraosseous
plasmacytoma
Surgery, or
Both
Testing every 3 to 6 months with:

Bone marrow aspiration and biopsy as needed
CBC
Blood chemistry tests: creatinine, albumin, and calcium
LDH and beta-2 microglobulin as needed
Serum free light chain assay
SPEP and SIFE
UPEP and UIFE
Bone survey as needed or every year
MRI, CT, PET/CT scans as needed
Follow-up tests
Chart 4.2 shows the recommended primary
treatment options for a solitary plasmacytoma. A

solitary plasmacytoma is when there is only a single
mass of myeloma cells. This chart also shows the
recommended tests for follow-up after primary
treatment.
After completing primary treatment, follow-up tests

are recommended every 3 to 6 months. These tests
are used to check how well treatment worked. An
outcome or improvement related to treatment is called
a treatment response. See page 41 to read about the
types of treatment responses.
Primary treatment is the main treatment given to rid

the body of cancer. Treatment options are based on
where the solitary plasmacytoma is located in the
body. An osseous solitary plasmacytoma begins in
bone marrow. An extraosseous solitary plasmacytoma
begins in soft tissue outside the bone.
Most of the follow-up tests given after treatment

are the same as those described in Chart 4.1 for
diagnosis and assessing symptoms. Ongoing,
frequent tests to measure M-protein levels are used
to check the status of the cancer to make sure
treatment is still working. (See Part 2 on page 14 for
more details on each test listed in the chart.)
Primary treatment
Because there is only one cancer mass in a solitary
plasmacytoma, treatment includes radiation, a local
therapy. For an extraosseous plasmacytoma, another
option is to remove the mass with surgery. (See Part
3 on page 22 for more details about each treatment.)
38
Treatment guide Solitary plasmacytoma
Next steps:
If test results show that the

plasmacytoma has come back after
primary treatment, local therapy
may be an option depending on the
location and size of the mass. If the
cancer has spread, see Chart 4.1 on
page 36 for recommended testing.

39
Treatment guide Smoldering multiple myeloma
4.3 Smoldering multiple myeloma

Chart 4.3 Smoldering myeloma treatment
Primary treatment
Clinical trial, or
Observation with testing every 3 to 6 months:
CBC
Blood chemistry tests: BUN, creatinine, and calcium
SPEP and SIFE
Serum free light chain assay as needed
UPEP and UIFE
Bone survey every year or for symptoms
MRI scan as needed
PET/CT scan as needed
Bone marrow aspiration and biopsy as needed
Flow cytometry as needed
Chart 4.3 shows the recommended primary
recommended every 3 to 6 months to check the

status of the cancer. (See Part 2 on page 14 for more
details about each test.)
treatment options for multiple myeloma that isnt

causing symptoms. This is called smoldering multiple
myeloma. Primary treatment is the main treatment
given to rid the body of cancer.
Smoldering myeloma often takes months or years to
progress to active (symptomatic) myeloma. For this
reason, treatment isnt needed right away. Joining a
clinical trial is strongly recommended if one is open
and is the right fit for you. Observation is another
option. Observation means that your doctor will watch
for cancer growth with regular follow-up tests. Many
of the tests used for follow-up are the same as those
described in Chart 4.1 for diagnosis and assessing
symptoms. During observation, follow-up tests are

Next steps:
If the cancer grows and starts causing

symptoms, see Chart 4.4.1 on page
42 for recommended treatments for
active myeloma.
40
Treatment guide
Measuring treatment response
Measuring treatment response

A treatment response is an
outcome or improvement
related to treatment.
Complete response
The response is defined by
Partial response
how well treatment is killing

myeloma cells and the severity
of symptoms. The main types of
treatment responses are listed to
the right. Complete and partial
responses are often jointly
referred to as response.
No M-proteins are found in the blood or urine and less than

5 out of 100 cells in the bone marrow are plasma cells.
The amount of M-proteins in the blood has decreased by

at least 50%. The amount of M-proteins in the urine has
decreased by at least 90%. There is no increase in the size or
number of bone lesions.
Stable disease
Tests do not show a complete or partial response as defined

above or progressive disease as defined below. And, there is
no increase in the size or number of bone lesions.
Progressive disease
One or more of the following has occurred: at least a 25%

increase in the amount of M-proteins in the blood and urine,
a 25% increase in the number of plasma cells in the bone
marrow, an increase in size or number of bone lesions, or an
increase in calcium levels not explained by other conditions.
Clinical relapse
One or more of the following has occurred: there are direct

signs of cancer growth, signs of organ damage, an increase in
the number or size (at least 50% larger) of plasmacytomas or
bone lesions, increased calcium levels, an increase in creatine
levels in blood, or a decrease in the number of red blood cells.
Relapse from complete response
One or more of the following has occurred: a return of

M-proteins in blood or urine, 5 or more out of 100 cells in the
bone marrow are plasma cells, new or enlarging bone lesions,
or high calcium levels not explained by other conditions.

41
Treatment guide
Active multiple myeloma
4.4 Active multiple myeloma

Chart 4.4.1 Primary treatment for active myeloma
Transplant status
Primary treatment
Preferred regimens
Bortezomib/dexamethasone,
Lenalidomide/low-dose dexamethasone,
Melphalan/prednisone/bortezomib,
Treatment will not

include a stem
cell transplant
Melphalan/prednisone/lenalidomide, or
Melphalan/prednisone/thalidomide
+ Adjunctive treatment
Other regimens
Dexamethasone,
Liposomal doxorubicin/vincristine/dexamethasone,
Melphalan/prednisone, or
Thalidomide/dexamethasone
Preferred regimens
Bortezomib/cyclophosphamide/dexamethasone,
Bortezomib/doxorubicin/dexamethasone,
Bortezomib/lenalidomide/dexamethasone,
Treatment will
include a stem
cell transplant
Bortezomib/thalidomide/dexamethasone, or
Lenalidomide/dexamethasone
Other regimens
Carfilzomib/lenalidomide/dexamethasone,
Dexamethasone,
Liposomal doxorubicin/vincristine/dexamethasone, or

42
+ Adjunctive treatment
Treatment guide
Chart 4.4.1 shows the primary treatment options
that are recommended for multiple myeloma that is

causing symptoms. This is called active myeloma.
Primary treatment is the main treatment given
to rid your body of cancer. Primary treatment
includes systemic therapies such as chemotherapy,
targeted therapy, and steroids. These drugs may
be given alone or in combination. Treatment for
active myeloma may or may not include a stem cell
transplant. When deciding if a stem cell transplant
is a good option for you, your doctor will consider
a number of factors. Some key factors include the
health of your liver, kidneys, and heart, as well as
your age and other current health problems.
Primary treatment
Your primary treatment options depend on whether or
not a stem cell transplant might be part of your overall
treatment. Some drugs can cause severe damage
to healthy cells in the bone marrow. This can make
it harder to harvest blood stem cells for a transplant.
Melphalan is an example of this type of drug. Thus,
melphalan is not recommended for primary treatment
if you might have a stem cell transplant later.
The primary treatment options are also split into two
groupspreferred regimens and other regimens.
Compared to other regimens, preferred regimens
work better, have less severe side effects, or both.
(See Part 3 on page 22 for more details about each
type of myeloma treatment.)
side effect is an unplanned or unwanted physical or

emotional response to treatment.
Recommended adjunctive treatments include:
Bisphosphonates for bone health
(recommended for all patients),
Drugs, radiation therapy, or surgery for bone
pain,
Drug treatment for high calcium levels,
Plasmapheresis for hyperviscosity,
Erythropoietin for anemia,
Vaccines and treatments for infections,
Blood thinners to prevent blood clots, and
Liquids and possible plasmapheresis to
prevent kidney damage.
Adjunctive treatments are recommended as needed
based on the symptoms and side effects you have.
Thus, you may not need every adjunctive treatment
listed above. Bone damage from myeloma is very
common, so bisphosphonates are recommended
for all patients. Drugs such as thalidomide and
lenalidomide can cause serious blood clots. If these
drugs are part of the primary treatment given, then
blood thinners are recommended. Blood thinners are
medications that thin out blood to treat or reduce the
risk of blood clots. Other adjunctive treatments may
be given as symptoms of myeloma or side effects of
myeloma treatment appear. For more details about
each adjunctive treatment, read page 28 in Part 3.
Adjunctive treatment
Next steps:
Adjunctive treatment is given along with primary

treatment for myeloma. It is given to assist the
primary treatment, such as by improving its safety or
how well it works. For myeloma, adjunctive treatment
includes supportive care to manage the symptoms of
myeloma and side effects of myeloma treatment. A
See Chart 4.4.2 on page 44 for

recommended follow-up after starting
primary treatment.

43
Treatment guide
Chart 4.4.2 Follow-up after primary treatment

Follow-up tests
Test results

as needed
CBC
Blood chemistry tests: BUN, creatinine,
and calcium
SPEP and SIFE
Serum free light chain assay as needed
UPEP and UIFE
Bone survey yearly or for symptoms
MRI scan as needed
PET/CT scan as needed
Next treatment
Autologous stem cell transplant,
Allogeneic stem cell transplant on clinical trial,
or
Treatment
response
Stay on primary treatment until best response,

then observation + maintenance treatment
No treatment
response
Treatment for relapse or progressive disease
Maintenance treatment options:

Preferred regimens
Bortezomib,
Lenalidomide, or
Thalidomide
Other regimens
Bortezomib + prednisone,
Bortezomib + thalidomide,
Interferon,
Steroids, or
Thalidomide + prednisone
Chart 4.4.2 shows the follow-up tests that are
Many of the tests used for follow-up will be the same

as those described in Chart 4.1 for diagnosis. A bone
marrow aspiration and biopsy may be done to check
if plasma cell levels in the bone marrow are falling. A
CBC will show if the number of blood cells is low for
each blood cell type. Blood chemistry tests check if
certain substances in your blood are too low or too
high. Tests of BUN, creatinine, and calcium levels
assess for symptoms of myeloma such as kidney
damage and bone damage. The other blood tests and
urine tests assess if M-protein levels are falling. (See
Part 2 on page 14 for more test details.)
recommended to check how well primary treatment

is working. It also shows the next treatments that
are recommended after primary treatment, based on
results of the follow-up tests.
Follow-up tests
Follow-up tests are recommended after 2 cycles of

primary treatment for active myeloma. These tests are
used to check for a treatment responsean outcome
or improvement related to treatment.

44
Treatment guide
Test results and next treatment
The next treatment recommendations are based on

how the myeloma responded to primary treatment.
To read about the types of treatment responses, see
Measuring treatment response on page 41.
If the myeloma responded to primary

treatment, then you have three treatment options
to choose from next. The first two options are only for
patients who are able to have a stem cell transplant.
This treatment destroys cells in the bone marrow with
chemotherapy and then replaces them with healthy
blood stem cells. An autologous stem cell transplant
uses your own stem cells. An allogeneic stem cell
transplant uses stem cells from another person,
called a donor.
For an autologous stem cell transplant, your stem cells
will be harvested after primary treatment when the
number of myeloma cells is low. Enough stem cells
must be collected for two transplants. This is needed
since you may have a tandem stem cell transplant or
a second transplant as later treatment. (See Part 3 on
page 26 for more details about stem cell transplants.)
After the allogeneic or autologous stem cell
transplant, the follow-up tests listed in Chart 4.4.2 will
be repeated to check for a treatment response. Tests
to check the level of M-proteins in your blood and
urine should be done at least every 3 months.
If you arent able to have a stem cell transplant, or you
dont want a transplant right away, then there is a third
option to choose from. The third option, for all patients,
is to continue primary treatment until no further
treatment response is seen with follow-up tests.
Afterward, you will begin observation and your doctor
will monitor the cancer with the follow-up tests listed
in Chart 4.4.2. During observation, tests to check the
level of M-proteins in your blood and urine should be
done at least every 3 months. Along with follow-up
tests you may also be given maintenance treatment.

Maintenance treatment is medicine given in a lower

dose or less frequently to maintain good primary
treatment results. Maintenance treatment options are
listed in the lower part of Chart 4.4.2. Compared to
other regimens, preferred regimens work better,
have less serious side effects, or both.
If the myeloma didnt respond to primary

treatment, then you will receive treatment for
relapse or progressive disease. A relapse is the

return of myeloma signs or symptoms after a period
of improvement (response). Progressive disease is
when myeloma continues to grow, spread, or get
worse. See Next steps.
Next steps:
If you had an allogeneic stem cell

transplant, see Chart 4.4.3 on
page 46 for recommendations. If
you had an autologous stem cell
transplant, see Chart 4.4.4 on page
48 for recommendations. If tests
showed that the myeloma didnt
respond to primary treatment, see
Chart 4.4.5 on page 50 for treatment
recommendations. Chart 4.4.5 also
covers recommended treatments
for myeloma progression or relapse
after observation or maintenance
treatment.
45
Treatment guide
Chart 4.4.3 Treatment after allogeneic stem cell transplant

Test results
Treatment options
Maintenance treatment on clinical trial, or
Treatment response
or stable disease
Observation
Additional treatment on or off clinical trial, or
Progressive disease
Donor lymphocyte infusion
Preferred regimens
Bortezomib,
Lenalidomide, or
Thalidomide
Other regimens
Interferon,
Steroids, or
Chart 4.4.3 shows the treatment options that
treatment is medicine given in a lower dose or less

frequently to maintain good initial treatment results.
Maintenance treatment options are listed in the lower
part of Chart 4.4.3. Compared to other regimens,
preferred regimens work better, have less serious
side effects, or both. The second option is to begin
observationa period of testing to watch for cancer
growth. If myeloma returns or gets worse after either
of these options, then you will have treatment for
progressive disease as described below.
If tests show a treatment response or stable

disease, then you have two treatment options to
If tests show progressive disease, then you
are recommended after an allogeneic stem cell

transplant. An allogeneic transplant is a treatment
in which you receive healthy blood stem cells from
another person. Which treatment is recommended
next depends on how the myeloma responded to
the stem cell transplant. A treatment response is
an outcome or improvement related to treatment.
See page 41 to read about the types of treatment
responses.
have two treatment options to choose from. The first

option is to receive additional treatment, possibly
within a clinical trial. Additional treatment is given
choose from. One option is to receive maintenance

treatment as part of a clinical trial. Maintenance

46
Treatment guide
after prior treatments failed to kill all of the cancer or

keep it away. (Options for additional treatment are
listed in Chart 4.4.6 on page 51.) The second option
is to receive a donor lymphocyte infusion. A donor
lymphocyte infusion is when you are given white
blood cells called lymphocytes from the same donor
used for the allogeneic stem cell transplant. (See
Part 3 on page 22 to read more about each type of
treatment for myeloma.)

47
Treatment guide
Chart 4.4.4 Treatment after autologous stem cell transplant

Test results
Response or
stable disease
Treatment options
Next treatment
Maintenance treatment,
Additional treatment on or
off clinical trial + autologous
stem cell transplant, or
Progressive
disease
Tandem stem cell transplant

+ maintenance treatment, or
Observation
Progressive
disease
Allogeneic stem cell transplant

on clinical trial
Additional treatment on or off clinical trial, or

Allogeneic stem cell transplant on clinical trial

Preferred regimens
Bortezomib,
Lenalidomide, or
Thalidomide
Other regimens
Interferon,
Steroids, or
Chart 4.4.4 shows the treatments that are
results. Maintenance treatment options are listed in

the lower part of Chart 4.4.4. Compared to other
regimens, preferred regimens work better, have less
serious side effects, or both. The second option is to
receive a tandem stem cell transplant with or without
maintenance treatment. A tandem transplant is a
second round of high-dose chemotherapy followed by
a second autologous stem cell transplant given within
6 months of the first transplant. The third option is to
begin observationa period of testing to watch for
cancer growth. (See Part 3 on page 22 to read more
about each type of treatment for myeloma.)
recommended after an autologous stem cell

transplant. An autologous stem cell transplant is
a treatment in which your blood stem cells are
removed, stored, and then returned. Which treatment
is recommended depends on how the myeloma
responded to the transplant. A treatment response
is an outcome or improvement related to treatment.
See page 41 to read about the types of treatment
responses.
If tests show a treatment response or stable

disease, you have three treatment options to choose
If tests show progressive disease after any of the

treatments described above, you have two more
treatment options to choose from. The first option
from. The first option is to receive maintenance

treatmentmedicine given in a lower dose or
less frequently to maintain good initial treatment

48
Treatment guide
is to receive additional treatment, possibly within a

clinical trial. Additional treatment is the treatment
given after prior treatments failed to kill all the cancer
or keep it away. (Options for additional treatment are
listed in Chart 4.4.6 on page 51.) Additional treatment
may be given with or without another autologous
stem cell transplant. A treatment response lasting at
least 2 to 3 years prior to progression is suggested
for consideration of another transplant. The second
option is to receive an allogeneic stem cell transplant
within a clinical trial. (See page 27 for more details
about the different types of stem cell transplants.)
If tests show progressive disease, then you
have two treatment options to choose from. One

option is to receive additional treatment, possibly
within a clinical trial. (Options for additional treatment
are listed in Chart 4.4.6 on page 51.) The other option
is to receive an allogeneic stem cell transplant as
part of a clinical trial. An allogeneic transplant is a
treatment in which you receive healthy blood stem
cells from another person. (See Part 3 on page
22 to read more about each type of treatment for
myeloma.)

49
Treatment guide
Chart 4.4.5 Treatment for relapse or progressive disease after primary treatment
Transplant status
Able to have a stem

cell transplant
Not able to have a

stem cell transplant
Treatment options
Next treatment
Autologous stem cell

transplant, or
Additional treatment on
or off clinical trial, or
Additional treatment
on or off clinical trial
Additional treatment
on or off clinical trial
Progressive
disease
Progressive
disease
Chart 4.4.5 shows the treatments that are
Palliative care
The first option is to receive an autologous stem cell

transplant. The second option is to receive additional
treatmentthe treatment given after prior treatments
failed to kill all the cancer or keep it away. Options
for additional treatment are listed in Chart 4.4.6 on
page 51. If follow-up tests show progressive disease
after the transplant or additional treatment, then you
have two more options. One option is to receive
additional treatment, possibly within a clinical trial.
The other option is to have an allogeneic stem cell
transplant within a clinical trial.
recommended for a relapse or progressive disease

after primary treatment. A relapse is the return
of myeloma signs or symptoms after a period of
improvement. Progressive disease is when myeloma
continues to grow, spread, or get worse.
Chart 4.4.5 includes options for myeloma that didnt
respond to primary treatment or that progressed
or relapsed after an initial treatment response.
Which treatment option is recommended depends
on whether or not you are able to have a stem cell
transplant. A stem cell transplant is a treatment that
destroys cells in the bone marrow with chemotherapy
and then replaces them with healthy blood stem cells.
An autologous stem cell transplant uses your own
stem cells. An allogeneic stem cell transplant uses
stem cells from another person, called a donor. (See
page 26 for more details about stem cell transplants.)
If you are not able to have a stem cell

transplant, then additional treatment is
recommended on or off a clinical trial. Options for

additional treatment are listed in Chart 4.4.6 on
page 51. If tests show progressive disease during
or after additional treatment, then palliative care is
recommended. Palliative care (also called supportive
care) is given to relieve symptoms of cancer and side
effects of cancer treatment. It doesnt aim to treat the
cancer, but aims to improve quality of life.
If you are able to have a stem cell transplant,

then you have two treatment options to choose from.

Allogeneic stem cell

transplant on clinical trial
50
Treatment guide
Chart 4.4.6 Additional treatment

Preferred regimens
Repeat primary treatment if it ended >6 months ago,
Bortezomib,
Bortezomib/lenalidomide/dexamethasone,
Bortezomib/liposomal doxorubicin,
Bortezomib/thalidomide/dexamethasone,
Carfilzomib,
Carfilzomib/lenalidomide/dexamethasone
Cyclophosphamide/bortezomib/dexamethasone,
Cyclophosphamide/lenalidomide/dexamethasone,
Dexamethasone/cyclophosphamide/etoposide/cisplatin,
Dexamethasone/thalidomide/cisplatin/doxorubicin/cyclophosphamide/etoposide + bortezomib,
High-dose cyclophosphamide,
Lenalidomide/dexamethasone,
Panobinostat/bortezomib/dexamethasone,
Pomalidomide/dexamethasone, or
Other regimens
Bendamustine,
Bortezomib/vorinostat, or
Lenalidomide/bendamustine/dexamethasone

51
Treatment guide
Notes
My notes

52

53
5 Making treatment
decisions
54
Have a treatment plan
57 Your role in planning

57
Getting a 2nd opinion
58
Questions to ask your doctors
62 Websites
62 Review
Cancer can be stressful. While

absorbing the fact that you have
cancer, you must also learn about
tests and treatments. And, the time
you have to decide on a treatment
plan may feel short. Parts 1 through
4 aimed to teach you about multiple
myeloma, its treatment, and other
challenges. Part 5 aims to help
you talk with your doctor and make
treatment decisions that are right for
you.

Learning you have cancer starts an unplanned

journey to an unknown place. A treatment plan is
like having a roadmap for your journey. It is a written
course of action through treatment and beyond. It can
help you, your loved ones, and your treatment team.
A treatment plan addresses all cancer care needs
while respecting your beliefs, wishes, and values.
It is likely to change and expand as you go through
treatment. The plan will include the role of your
doctors and how you can help yourself. A treatment
plan often has the following parts:
Cancer information
Cancer can greatly differ even when people have

cancer in the same organ. Test results that describe
the cancer are reported in the treatment plan. Such
test results include the number of plasma cells and
levels of M-proteins, calcium, and creatinine. If done,
test results of known gene changes are also included.
See Part 2 on page 14 to read more about the tests
used for multiple myeloma.
54
Your treatment team
Treating multiple myeloma takes a team approach. A

hematologist is a doctor whos an expert in treating
diseases of the blood. A medical oncologist is a
doctor whos an expert in treating cancer with drugs.
A radiation oncologist is an expert at treating cancer
with radiation. A surgeon is an expert in operations to
remove or repair a part of the body. A pathologist is
an expert in testing cells and tissue to find disease.
Your primary care doctor can also be part of your
team. He or she can help you express your feelings
about treatments to the team. Treatment of other
medical problems may be improved if he or she is
informed of your cancer care. Besides doctors, you
may receive care from nurses, social workers, and
other health experts. Ask to have the names and
contact information of your health care providers
included in the treatment plan.
Cancer treatment
There is no single treatment practice that is best for

all patients. There is often more than one treatment
option, including clinical trials. Clinical trials study how
well a treatment works and its safety.
A guide to myeloma treatment options can be found
in Part 4. The treatment that you and your doctors
agree on should be reported in the treatment plan. It
is also important to note the goal of treatment and the
chance of a good treatment outcome. All known side
effects should be listed and the time required to treat
them should be noted. See Part 3 for a list of some of
the possible side effects of myeloma treatments.
Your treatment plan may change because of new
information. You may change your mind about
treatment. Tests may find new results. How well
the treatment is working may change. Any of these
changes may require a new treatment plan.

Stress and symptom control
Cancer and its treatments can cause bothersome

symptoms. The stress of having cancer can also
cause symptoms. There are ways to treat many
symptoms, so tell your treatment team about any that
you have.
You may lose sleep before, during, and after
treatment. Getting less sleep can affect your
mood, conversations, and ability to do daily tasks.
If possible, allow yourself to rest, let people do
things for you, and talk with your doctor about sleep
medication. Behavioral sleep medicinea type of talk
therapymay also help.
Feelings of anxiety and depression are common
among people with cancer. At your cancer center,
cancer navigators, social workers, and other experts
can help. Help can include support groups, talk
therapy, or medication. Some people also feel better
by exercising, talking with loved ones, or relaxing.
You may be unemployed or miss work during
treatment. Or, you may have too little or no health
insurance. Talk to your treatment team about work,
insurance, or money problems. They will include
information in the treatment plan to help you manage
your finances and medical costs.
Survivorship care
Cancer survivorship begins on the day you learn

of having myeloma. For many survivors, the end of
active treatment signals a time of celebration but also
of great anxiety. This is a very normal response. You
may need support to address issues that arise from
not having regular visits with your cancer care team.
In addition, your treatment plan should include a
schedule of follow-up cancer tests, treatment of longterm side effects, and care of your general health.
55
Advance care planning
One study found that patients and caregivers had a

better quality of life when hospice care was started
early.
Talking with your doctor about your prognosis can

help with treatment planning. If the cancer cant be
controlled or cured, a care plan for the end of life can
be made. However, such talks often happen too late
or not at all. Your doctor may delay these talks for
fear that you may lose hope, become depressed, or
have a shorter survival. Studies suggest that these
fears are wrong. Instead, there are many benefits to
advance care planning. It is useful for:

An advance directive describes the treatment youd

want if you werent able to make your wishes known.
It also can name a person whom youd want to make
decisions for you. It is a legal paper that your doctors
have to follow. It can reveal your wishes about lifesustaining machines, such as feeding tubes. It can
also include your treatment wishes if your heart or
lungs were to stop working. If you already have an
advance directive, it may need to be updated to be
legally valid.
Knowing what to expect,

Making the most of your time,
Lowering the stress of caregivers,
Having your wishes followed,
Having a better quality of life, and
Getting good care.
Advance care planning starts with an honest talk

between you and your doctors. You dont have to
know the exact details of your prognosis. Just having
a general idea will help with planning. With this
information, you can decide at what point youd want
to stop chemotherapy or other treatments, if at all.
You can also decide what treatments youd want for
symptom relief, such as radiation therapy, surgery, or
medicine.
Another part of the planning involves hospice care.
Hospice care doesnt include treatment to fight the
cancer but rather to reduce symptoms caused by
cancer. Hospice care may be started because you
arent interested in more cancer treatment, no other
cancer treatment is available, or because you may
be too sick for cancer treatment. Hospice care allows
you to have the best quality of life possible. Care is
given all day, every day of the week. You can choose
to have hospice care at home or at a hospice center.

56
Making treatment decisions Your role in planning | Getting a 2nd opinion
Your role in planning
Getting a 2nd opinion
The role patients want in treatment planning

differs. Your doctors and treatment team will give
you the information you need to make informed
choices. But, you may prefer to let others take
the lead in deciding your treatment. This may
be due to a high level of stress. It may be hard
to hear or know what others are saying. Stress,
pain, and drugs can limit your ability to make
good decisions. You may have never heard
the words used to describe myeloma, tests, or
treatments. Likewise, you may think that your
judgment isnt any better than your doctors.
The time around a cancer diagnosis can be very

stressful. People with cancer often want to start
treatment as soon as possible. They want to
make the cancer go away before it spreads any
farther. While cancer cant be ignored, there is
time to think about and choose which treatment
plan is best for you.
You may rely on your doctors alone to make the

right decisions. You can also have loved ones
help. They can gather information, speak on your
behalf, and share in decision-making with your
doctors. Even if others decide which treatment
you will receive, you still have to agree by signing
a consent form.
On the other hand, you may prefer to take the
lead or share in decision-making. In shared
decision-making, you and your doctors share
information, weigh the options, and agree on a
treatment plan. Your doctors know the science of
treating myeloma. But, you know your personal
concerns and goals. By working together, you
may feel more comfortable and satisfied with
your care and treatment plan. Youll likely get the
treatment you want, at the place you want, and
by the doctors you want.

You may wish to have another doctor review your

test results and the treatment plan your doctor
has recommended. This is called getting a 2nd
opinion. You may completely trust your doctor,
but a 2nd opinion on which treatment is right for
you can help.
Copies of all of the test results need to be sent
to the doctor giving the 2nd opinion. Some people
feel uneasy asking for copies from their doctors.
However, a 2nd opinion is a normal part of cancer
care.
When doctors have cancer, most will talk with
more than one doctor before choosing their
treatment. Whats more, some health plans
require a 2nd opinion. If your health plan doesnt
cover the cost of a 2nd opinion, you have the
choice of paying for it yourself. Choosing your
cancer treatment is a very important decision. It
can affect length and quality of life.
57
Questions about testing

1. What tests will I have?
2. Where will the tests take place? Will I have to go to the hospital?
3. How long will it take? Will I be awake?
4. Will it hurt? Will I need anesthesia?
5. What are the risks? What are the chances of infection or bleeding afterward?
6. How do I prepare for testing? Should I not take aspirin? Should I not eat beforehand?
7. Should I bring a list of my medications?
8. Should I bring someone with me?
9. How long will it take for me to recover? Will I be given an antibiotic or other drug afterward?
10. How soon will I know the test results and who will explain them to me? If a biopsy is done, will I
get a copy of the results?
11. Who will talk with me about the next steps? When?
12. For a bone marrow aspiration or bone marrow biopsy: Will you remove the sample of bone
marrow from the hip or from another bone?

58
Questions about treatments

1. What are my treatment options?
2. Is there a clinical trial I can take part in?
3. Will I have more than one treatment?
4. What are the risks and benefits of each treatment for multiple myeloma?
5. Will my age, general health, extent of multiple myeloma, and other medical conditions limit my
treatment choices?
6. Do I have to get treated?
7. Where will I be treated? Will I have to stay in the hospital or can I go home after each treatment?
8. What can I do to prepare for treatment? Should I stop taking my medications?
9. How soon should I start treatment? How long does treatment take?
10. How much will the treatment cost? How can I find out how much my insurance company will
cover?
11. How likely is it that Ill be cancer-free after treatment?
12. What symptoms should I look out for while being treated for multiple myeloma?
13. When will I be able to return to my normal activities?
14. What is the chance that the myeloma will come back or spread?
15. What should I do after I finish treatment?
16. Are there supportive services that I can get involved in? Support groups?

59
Questions about stem cell transplants

1. Am I considered a candidate for high-dose chemotherapy and autologous stem cell transplant?
2. If two autologous transplants are considered, what is the optimal timing? For example, should the
second one be planned in advance or deferred until a relapse?
3. Am I a candidate for an allogeneic stem cell transplant? If so, how should my family members be
tested to see if their bone marrow matches mine?
4. Should the allogeneic transplant be the first transplant, or should this transplant only be done if
the cancer worsens after a prior autologous transplant?
5. What are the risks of each of these strategies, both short-term and long-term?
6. How long does each strategy control the myeloma, and what are the chances of long-term control
or even cure?
7. If I cant have a stem cell transplant, what are the other options?

60
Questions about clinical trials

1. Is there a clinical trial that I could take part in?
2. What is the purpose of the study?
3. What kinds of tests and treatments does the study involve?
4. What does the treatment do?
5. Has the treatment been used before? Has it been used for other types of cancers?
6. Will I know which treatment I receive?
7. What is likely to happen to me with, or without, this new treatment?
8. What are my other choices? What are their benefits and risks?
9. How might the study change my daily life?
10. What side effects can I expect from the study? Can the side effects be controlled?
11. Will I have to stay in the hospital? If so, how often and for how long?
12. Will the study cost me anything? Will any of the treatment be free?
13. If Im harmed as a result of the research, what treatment might I get?
14. What type of long-term follow-up care is part of the study?

61
Websites | Review
Websites
Review
American Cancer Society

www.cancer.org/cancer/multiplemyeloma/
detailedguide/index
A treatment plan can help you through

treatment and beyond.
It covers many issuestest results,
treatments, and supportive programs.
National Cancer Institute

www.cancer.gov/types/myeloma/patient/
myeloma-treatment-pdq
You can choose how active a role to have

in planning your treatment.
You may wish to get a 2nd opinion on your
treatment plan.
Multiple Myeloma Research Foundation

www.themmrf.org/
International Myeloma Foundation
www.myeloma.org
Leukemia & Lymphoma Society
www.lls.org/disease-information/myeloma
National Coalition for Cancer Survivorship
www.canceradvocacy.org/toolbox
NCCN
www.nccn.org/patients/

62
Glossary
Dictionary
Acronyms

63
Glossary Dictionary
Dictionary
active myeloma
Myeloma that has spread throughout the bone marrow (soft
tissue in the center of bones where blood cells are made)
and is causing symptoms.
apheresis
A procedure in which stem cells are removed from blood.
asymptomatic
Having no signs or symptoms of disease.
additional treatment
Treatment given after previous treatments failed to kill all the
cancer or keep it away.
autologous stem cell transplant

A cancer treatment that removes, stores, then returns a
patients immature blood-forming cells (blood stem cells).
adjunctive treatment
Medicine for symptoms of myeloma and side effects of
myeloma treatment that is given at the same time as the
main cancer treatment.
B-cell
A type of white blood cell that turns into a plasma cell in
response to germs.
Bence Jones myeloma
Condition in which myeloma cells make only free light
chains and no complete M-proteins. Also called light chain
myeloma.
albumin
The main protein in blood plasma (yellowish part of blood).
allogeneic stem cell transplant
A treatment in which the patient receives healthy, immature
blood-forming cells (blood stem cells) from another person.
beta-2 microglobulin
A small protein made by many cells, including white blood
cells and myeloma cells.
amyloid
An abnormal protein that is formed by clumps of excess light
chains and can damage organs.
biopsy
Removal of small amounts of tissue from the body to be
tested for disease.
amyloidosis
A health condition in which a protein called amyloid builds up
in and damages organs.
bisphosphonates
Drugs that help improve bone strength and prevent loss of
bone mass.
anemia
A health condition in which the number of red blood cells is
low.
blood chemistry test

A test that measures the amount of certain substances in the
blood to check for signs of disease.
anesthesia
Loss of feeling with or without loss of wakefulness caused by
drugs.
blood clot
A mass of blood that forms when blood platelets, proteins,
and cells stick together.
antibiotic
A drug used to treat infections caused by bacteria.
blood stem cell

An immature cell from which all other types of blood cells are
made.
antibody
Protein made by plasma cells (a type of white blood
cell) that helps the body fight off infections. Also called
immunoglobulin.

bloodstream
Blood that flows throughout the body in small tubes called
blood vessels
64
Glossary Dictionary
blood test
A test done on a sample of blood to check for signs of
disease.
chromosomes
Long strands that contain bundles of coded instructions in
cells for making and controlling cells.
blood thinner
A drug that thins out the blood to treat or reduce the risk of
blood clots.
clinical trial
Research on a test or treatment to assess its safety or how
well it works.
blood urea nitrogen (BUN)

A waste product made by the liver and filtered out of blood
into urine by the kidneys.
combination regimen
The use of two or more drugs.
bone densitometry
A test that uses x-rays to make pictures that show how
strong or thin bones are.
bone lesion
An area of bone damage or abnormal tissue in the bone.
bone marrow
The soft, sponge-like tissue in the center of most bones
where blood cells are made.
bone marrow aspiration
The removal of a small amount of liquid bone marrow (soft
tissue in the center of bones where blood cells are made) to
test for disease.
bone marrow biopsy
The removal of a small amount of solid bone and bone
marrow (soft tissue in the center of bones where blood cells
are made) to test for disease.
bone survey
A set of x-rays of the entire skeleton to look for broken or
damaged bones. Also called skeletal survey.
calcium
A mineral needed for healthy teeth, bones, and other body
tissues.
cells
The building blocks of tissues in the body.
central venous catheter
A thin, flexible tube that is inserted into a vein in the upper
arm, thigh, neck, or below the collarbone.
chemotherapy
Drugs that kill fast-growing cells throughout the body,
including normal cells and cancer cells.

complete blood count (CBC)

A test of the number of blood cells.
compression fracture
A break (fracture) in a bone caused by the collapse of bones
in the spine.
computed tomography (CT) scan
A test that uses x-rays from many angles to make a picture
of the inside of the body.
contrast
A dye put into your body to make clearer pictures during
imaging tests.
core needle biopsy
Use of a wide, hollow needle to remove a large sample of
tissue from the body to test for cancer cells.
creatinine
A waste product of muscles that is filtered out of blood into
urine by the kidneys.
cryopreservation
The process of cooling and storing cells, tissues, or organs
at very cold temperatures.
cycle
Days of treatment followed by days of rest.
cytogenetics
Test that analyzes chromosomes (long strands of bundles
of genes) in cells to check for abnormal changes in genes
(coded instructions in cells for making and controlling cells).
diagnosis
The process of identifying a disease.
donor
A person who gives blood, cells, tissue, or an organ to
another person.
65
Glossary Dictionary
donor lymphocyte infusion

Treatment in which the patient receives white blood cells
called lymphocytes from the same donor used for the
allogeneic stem cell transplant.
gene
A set of coded instructions in cells needed to make new cells
and control how cells behave.
gene mutation
Abnormal change in the instructions in cells for making and
controlling cells.
electrolytes
Minerals in blood that carry an electric charge and control
some body functions.
general anesthesia
A controlled loss of wakefulness from drugs.
erythropoietin
A drug used to treat patients with low red blood cell counts.
genetic tests
Tests of the instructions in cells for making and controlling
cells.
external beam radiation therapy (EBRT)

Radiation therapy (use of high-energy rays to destroy cancer
cells) received from a machine outside the body.
graft-versus-host disease (GVHD)

A disease that occurs when transplanted stem cells
(immature blood-forming cells) attack a patients normal
cells.
extraosseous
Occurring outside the bone.
fatigue
Severe tiredness despite getting enough sleep.
graft-versus-tumor (GVT) effect

An attack on cancer cells by transplanted stem cells
(immature blood-forming cells).
fat pad
The fat that is just under the skin of the belly area
(abdomen).
granulocyte
A type of white blood cell named for its small particles
(granules).
fine-needle aspiration biopsy

Use of a thin needle to remove a small amount of tissue from
the body to test for cancer cells.
harvest
The process of removing blood stem cells from a person.
flow cytometry
A test that measures myeloma cells in the bone marrow (soft
tissue in the center of bones where blood cells are made).
heavy chain
The longer protein chain that is part of an antibody (protein
that helps the body fight off infections).
fluorescence in situ hybridization (FISH)

A lab test that assesses genes (coded instructions for
making and controlling cells) or chromosomes (long strands
containing bundles of genes) in cells to check for abnormal
changes in genes.
hematologist
A doctor whos an expert in diseases of the blood.
high-dose chemotherapy
An intensive drug treatment to kill cancer and diseasefighting cells so transplanted stem cells arent rejected by the
body.
follow-up test
Tests done after the start of treatment to check how well
treatment is working.
hormone
A chemical in the body that activates cells or organs.
fracture
A crack or break in a bone.
human leukocyte antigen (HLA)

Special proteins on the surface of cells that help the body to
tell its own cells apart from foreign cells.
free light chain

The unattached, shorter fragments of M-proteins that are
made by myeloma cells.

human leukocyte antigen (HLA) type

The unique set of proteins on the surface of cells that helps
the body to tell its own cells apart from foreign cells.
66
Glossary Dictionary
human leukocyte antigen (HLA) typing

A blood test that finds a persons HLA typethe unique set
of proteins on the surface of cells that helps the body to tell
its own cells apart from foreign cells.
light chain myeloma

Condition in which myeloma cells make only free light chains
and no complete M-proteins. Also called Bence Jones
myeloma.
hyperviscosity
A condition in which the blood becomes very thick because
of too many proteins in the blood.
liver
Organ that removes waste from the blood.
imaging test
A test that makes pictures (images) of the inside of the body.
immune cell
A cell that helps fight disease or infection.
immune system
The bodys natural defense against infection and disease.
immunoglobulin
A protein made by plasma cells that helps fight off infection.
Also called antibody.
inflammation
Redness, heat, pain, and swelling from injury or infection.
intestine
The organ that food passes through after leaving the
stomach.
intravenous (IV)
Given by a needle or tube inserted into a vein.
karyotyping
A process that examines a map, or karyotype, of a cells
chromosomeslong strands of bundles of coded instructions
for controlling cells.
kidneys
A pair of organs that filter blood and remove waste from the
body through urine.
kyphoplasty
Surgery to support the spine with a balloon-like device and a
type of cement.
lactate dehydrogenase (LDH)
A protein found in the blood that is involved in energy
production in cells.
light chain
The shorter protein chain that is part of an antibody.

local anesthesia
A controlled loss of feeling in a small area of the body
caused by drugs.
local therapy
Treatment that affects cells in one specific area of the body
only.
lymphocyte
A type of white blood cell that helps to protect the body from
infection.
magnetic resonance imaging (MRI) scan
A test that uses radio waves and powerful magnets to view
parts of the inside of the body and how they are working.
maintenance treatment
Treatment given in a lower dose or less frequently to
maintain good treatment results.
medical history
All health events and medications taken to date.
medical oncologist
A doctor whos an expert in treating cancer with drugs.
microscope
A tool that uses lenses to see very small things the eyes
cant.
mini transplant
A cancer treatment that uses low doses of chemotherapy
before giving the patient healthy, immature blood-forming
cells (blood stem cells) taken from another person called a
donor.
M-protein
An abnormal antibody made by myeloma cells that doesnt
fight germs. Also called monoclonal protein.
multiple myeloma
A cancer of plasma cells (white blood cells that make
germ-fighting proteins) that has spread throughout the bone
marrow (soft tissue in the center of bones where blood cells
are made).
67
Glossary Dictionary
myeloma cell
An abnormal plasma cell that grows and divides all the time.
positron emission tomography (PET) scan

A test that uses radioactive material to see the shape and
function of organs and tissues inside the body.
observation
A period of testing without treatment or right after treatment
to check for cancer growth.
positron emission tomography/computed

tomography (PET/CT) scan
A test that uses radioactive material and x-rays to see the
shape and function of organs and tissues inside the body.
oligosecretory myeloma
Myeloma that makes very few or no M-proteins. Also called
nonsecretory myeloma.
primary treatment
The main treatment used to rid the body of cancer.
organ
A part of the body that performs a certain function.
prognosis
The likely or expected course and outcome of a disease.
orthopedic surgeon
A surgeon whos an expert in operations of the bones.
progression
The course of disease as it gets worse or spreads in the
body.
osseous
Occurring inside the bone.
progressive disease
Cancer that is growing, spreading, or getting worse.
osteonecrosis
The death of bone cells.
protein
A chain of small chemical compounds important to every cell.
pathologist
A doctor whos an expert in testing cells and tissue to find
disease.
radiation oncologist
A doctor whos an expert in treating cancer with radiation.
physical exam
A review of the body by a health expert for signs of disease.
radiation therapy
The use of high-energy rays (radiation) to destroy cancer
cells.
plasma
The yellowish liquid part of blood that carries blood cells.
radiotracer
Matter with energy that is put into the body to make pictures
clearer.
plasma cell
A type of white blood cell (immune cell) that makes germfighting proteins.
red blood cell

A type of blood cell that carries oxygen from the lungs to the
rest of the body.
plasma cell labeling index

A test that shows how many myeloma cells are dividing and
how fast they are doing it.
plasmacytoma
A mass formed by abnormal plasma cells (myeloma cells).
regimen
A treatment plan that specifies the dose, schedule, and
duration of treatment.
plasmapheresis
A process that removes excess proteins, such as M-proteins,
from the blood.
regional anesthesia
A controlled, temporary loss of feeling or awareness in a part
of the body caused by drugs without loss of wakefulness.
platelet
A type of blood cell that forms blood clots to control bleeding.
relapse
The return of myeloma signs or symptoms after a period of
improvement.
pneumonia
A severe inflammation of the lungs.

sedative
A drug that helps a person to relax or go to sleep.
68
Glossary Dictionary
serum free light chain assay

A blood test that measures the amount of the shorter
fragments of the proteins made by myeloma cells.
supportive care
Treatment for symptoms of cancer or side effects of cancer
treatment.
serum immunofixation electrophoresis (SIFE)

A test used to identify the type of M-proteins in the blood.
surgeon
A doctor whos an expert in operations to remove or repair a
part of the body.
serum protein electrophoresis (SPEP)

A test that measures the amount of M-proteins in the blood.
serum quantitative immunoglobulins
A test that measures the amount of each type of antibody in
the blood.
serum viscosity
A test that measures the thickness of blood.
side effect
An unhealthy or unpleasant physical or emotional response
to treatment.
single agent
The use of one drug.
surgery
An operation to remove or repair a part of the body.
symptom
A physical or mental problem a person experiences that may
indicate a certain disease or health condition.
systemic therapy
Drugs used to treat cancer cells throughout the body.
tandem stem cell transplant
Treatment in which a planned second round of high-dose
chemotherapy and autologous stem cell transplant are given
within 6 months of the first transplant.
smoldering myeloma
Myeloma that isnt causing symptoms or damaging organs.
targeted therapy
Treatment with drugs that target a specific or unique feature
of cancer cells.
solitary plasmacytoma
Cancer that is one mass of myeloma cells (abnormal plasma
cells that grow and divide all the time).
tissue biopsy
Removal of a small amount of tissue from the body to test for
disease.
spine
The bones, muscles, and other tissues along the back from
the base of the skull to the tailbone.
total protein (urine)

A test that measures the amount and type of protein in urine
collected over a 24-hour period.
splint
A device used to support a broken bone and hold it in place.
transfusion
Replacing lost blood with new blood.
stable disease
Cancer that is not getting worse or better in terms of extent
or severity.
treatment plan
A written course of action through cancer treatment and
beyond.
stem cell
An immature cell from which other types of cells develop.
treatment response
An outcome or improvement related to treatment.
stem cell transplant

Treatment that uses chemotherapy to destroy bone marrow
(soft tissue in the center of bones where blood cells are
made) and then replaces it with healthy blood stem cells.
tumor burden
The amount or extent of cancer in the body.
steroid
A drug used to reduce swelling, redness, and pain, but also
to kill myeloma cells.

U.S. Food and Drug Administration (FDA)

A federal government agency that regulates drugs and food.
urine immunofixation electrophoresis (UIFE)
A test that identifies the type of M-proteins in the urine.
69
Glossary Dictionary
urine protein electrophoresis (UPEP)

A test that shows the amount of M-proteins in the urine.
vertebrae
The chain of 33 bones in the back that protect a vital group
of nerves.
vaccine
A biological agent inserted into the body to prevent a
disease.
vertebroplasty
A procedure to strengthen bones in the spine with bone
cement.
vein
A small tube that carries blood to the heart from anywhere in
the body.

white blood cell

A type of blood cell that fights infection.
70
Glossary Acronyms
Acronyms
BUN
blood urea nitrogen
UIFE
urine immunofixation electrophoresis
CBC
complete blood count
UPEP
urine protein electrophoresis
CT
computed tomography
NCCN Abbreviations and Acronyms
EBRT
external beam radiation therapy
NCCN
National Comprehensive Cancer Network
FDA
U.S. Food and Drug Administration
NCCN Patient Guidelines

FISH
fluorescence in situ hybridization
NCCN Guidelines
NCCN Clinical Practice Guidelines in Oncology
GVHD
graft-versus-host disease
GVT
graft-versus-tumor
HLA
human leukocyte antigen
IV
intravenous
LDH
lactate dehydrogenase
MRI
magnetic resonance imaging
PET
positron emission tomography
PET/CT
positron emission tomography/computed tomography
SIFE
serum immunofixation electrophoresis
SPEP
serum protein electrophoresis

71
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73
NCCN Panel Members
NCCN Panel Members for

Multiple Myeloma
Kenneth C. Anderson, MD/Chair
Craig Hofmeister, MD, MPH
Steven P. Treon, MD, PhD
William Bensinger, MD/Vice Chair
Carol Ann Huff, MD
Donna M. Weber, MD
Melissa Alsina, MD
Adetola Kassim, MD, MS
Joachim Yahalom, MD
Djordje Atanackovic, MD
Amrita Y. Krishnan, MD
Dana-Farber/Brigham and Womens

Cancer Center | Massachusetts General
Hospital Cancer Center
Fred Hutchinson Cancer Research Center/

Seattle Cancer Care Alliance
Moffitt Cancer Center
Huntsman Cancer Institute

at the University of Utah
J. Sybil Biermann, MD
University of Michigan
Comprehensive Cancer Center
Jason C. Chandler, MD
St. Jude Childrens Research Hospital/

The University of Tennessee
Health Science Center
Caitlin Costello, MD
UC San Diego Moores Cancer Center
Benjamin Djulbegovic, MD, PhD

Henry C. Fung, MD
Fox Chase Cancer Center
Cristina Gasparetto, MD
Duke Cancer Institute
Kelly Godby, MD
University of Alabama at Birmingham

The Ohio State University Comprehensive

Cancer Center James Cancer Hospital
and Solove Research Institute
The Sidney Kimmel Comprehensive

Cancer Center at Johns Hopkins
Vanderbilt-Ingram Cancer Center
City of Hope Comprehensive Cancer Center
Michaela Liedtke, MD
Stanford Cancer Institute
Matthew Lunning, DO
Fred & Pamela Buffett Cancer Center
Noopur Raje, MD

Seema Singhal, MD
Robert H. Lurie Comprehensive Cancer

Center of Northwestern University
Clayton Smith, MD
University of Colorado Cancer Center
George Somlo, MD
City of Hope Comprehensive Cancer Center
Keith Stockerl-Goldstein, MD
Siteman Cancer Center at BarnesJewish Hospital and Washington

University School of Medicine
Francisco Hernandez-Ilizaliturri, MD
Roswell Park Cancer Institute
For disclosures, visit www.nccn.org/about/disclosure.aspx.

74

The University of Texas

MD Anderson Cancer Center
Memorial Sloan Kettering Cancer Center

Fred & Pamela Buffett
Cancer Center
Omaha, Nebraska
800.999.5465
nebraskamed.com/cancer
Case Comprehensive Cancer Center/

University Hospitals Seidman
Cancer Center and Cleveland Clinic
Taussig Cancer Institute
Cleveland, Ohio
800.641.2422 UH Seidman Cancer Center
uhhospitals.org/seidman
866.223.8100 CC Taussig Cancer Institute
my.clevelandclinic.org/services/cancer
216.844.8797 Case CCC
case.edu/cancer
City of Hope Comprehensive

Cancer Center
Los Angeles, California
800.826.4673
cityofhope.org
The Sidney Kimmel

Comprehensive Cancer
Center at Johns Hopkins
Baltimore, Maryland
410.955.8964
hopkinskimmelcancercenter.org
Robert H. Lurie Comprehensive

Cancer Center of Northwestern
University
Chicago, Illinois
866.587.4322
cancer.northwestern.edu
Mayo Clinic Cancer Center
Phoenix/Scottsdale, Arizona
Jacksonville, Florida
Rochester, Minnesota
800.446.2279 Arizona
904.953.0853 Florida
507.538.3270 Minnesota
mayoclinic.org/departments-centers/mayoclinic-cancer-center
St. Jude Childrens

Research Hospital/
The University of Tennessee
Health Science Center
Memphis, Tennessee
888.226.4343 stjude.org
901.683.0055 westclinic.com
Stanford Cancer Institute

Stanford, California
877.668.7535
cancer.stanford.edu
University of Alabama at Birmingham

Birmingham, Alabama
800.822.0933
www3.ccc.uab.edu
UC San Diego Moores Cancer Center

La Jolla, California
858.657.7000
cancer.ucsd.edu
Memorial Sloan Kettering

Cancer Center
UCSF Helen Diller Family

University of Colorado Cancer Center
Duke Cancer Institute
Tampa, Florida
800.456.3434
moffitt.org
University of Michigan
Fox Chase Cancer Center
The Ohio State University

Comprehensive Cancer Center James Cancer Hospital and
Solove Research Institute
Dana-Farber/Brigham and
Womens Cancer Center
Massachusetts General Hospital
Cancer Center
Boston, Massachusetts
877.332.4294
dfbwcc.org
massgeneral.org/cancer
Durham, North Carolina
888.275.3853
dukecancerinstitute.org
New York, New York

800.525.2225
mskcc.org
Philadelphia, Pennsylvania
888.369.2427
foxchase.org
Columbus, Ohio
800.293.5066
cancer.osu.edu
Huntsman Cancer Institute

at the University of Utah
Roswell Park Cancer Institute
Salt Lake City, Utah

877.585.0303
huntsmancancer.org
Fred Hutchinson Cancer

Research Center/
Seattle Cancer Care Alliance
Seattle, Washington
206.288.7222 seattlecca.org
206.667.5000 fredhutch.org

Buffalo, New York

877.275.7724
roswellpark.org
Siteman Cancer Center

at Barnes-Jewish Hospital
and Washington University
School of Medicine
St. Louis, Missouri
800.600.3606
siteman.wustl.edu
San Francisco, California

800.689.8273
cancer.ucsf.edu
Aurora, Colorado
720.848.0300
coloradocancercenter.org
Ann Arbor, Michigan

800.865.1125
mcancer.org
The University of Texas

MD Anderson Cancer Center
Houston, Texas
800.392.1611
mdanderson.org
Vanderbilt-Ingram Cancer Center

Nashville, Tennessee
800.811.8480
vicc.org
Yale Cancer Center/

Smilow Cancer Hospital
New Haven, Connecticut
855.4.SMILOW
yalecancercenter.org
75
Index
Index
active myeloma 10, 12, 18, 19, 27, 37, 40, 4244
progressive disease 41, 4446, 4850
additional treatment 23, 4651
radiation therapy 22, 23, 27, 29, 32, 38, 43, 56
adjunctive treatment 28, 29, 32, 42, 43
side effect 15, 23, 24, 2630, 32, 43, 45, 46, 48, 50, 55
allogeneic stem cell transplant 27, 28, 32, 37, 4450
smoldering myeloma 10, 12, 37, 40
anemia 10, 24, 28, 29, 43
solitary plasmacytoma 8, 12, 18, 22, 23, 32, 3739
autologous stem cell transplant 27, 32, 44, 45, 4850
stem cells 6, 7, 15, 2628, 32, 43, 45, 46, 4850
biopsy 17, 18, 3638, 40, 44
stem cell transplant 2628, 32, 37, 4250, 60
bisphosphonate 19, 28, 43
steroid 22, 24, 25, 43, 44, 46, 48
blood stem cell 6, 7, 15, 26, 28, 32, 43, 45, 46, 4850
supportive care 28, 29, 43, 50
blood test 15, 16, 36, 44
surgery 22, 23, 28, 32, 38, 43, 56
bone damage 10, 11, 19, 20, 28, 29, 36, 37, 43, 44
symptom 1012, 18, 22, 28, 32, 3638, 40, 41, 4345, 50,
bone marrow 68, 10, 12, 15, 17, 18, 20, 23, 24, 26, 28,
55, 56
29, 32, 37, 38, 41, 4345, 50
targeted therapy 2225, 32, 43
bone marrow aspiration 17, 26, 3638, 40, 44
treatment response 38, 41, 4446, 4850
bone marrow biopsy 17, 18, 3638, 40, 44
urine test 16, 20, 36, 44
chemotherapy 2228, 32, 43, 45, 48, 50, 56

clinical trial 30, 32, 40, 44, 46, 4850, 55, 61
follow-up test 38, 40, 44, 45, 50
gene 8, 18, 22, 37, 54
graft-versus-host disease (GVHD) 28
graft-versus-tumor (GVT) effect 27
imaging test 18, 19, 37
kidney damage 11, 16, 29, 43, 44
maintenance treatment 23, 4446, 48
M-protein 912, 15, 16, 29, 3638, 41, 44, 45, 54
myeloma cell 812, 15, 16, 18, 19, 22, 23, 26, 27, 29, 32,
34, 37, 38, 41, 45
plasma cell 69, 12, 18, 26, 36, 37, 41, 44, 54
primary treatment 23, 27, 28, 3840, 4245, 50

76
Multiple Myeloma
Version 1.2015
NCCN Foundation gratefully acknowledges Bristol-Myers Squibb, Takeda Oncology and ONYX Pharmaceuticals, Inc., a subsidiary of
Amgen Inc. for their support in making available these NCCN Guidelines for Patients. NCCN independently develops and distributes the
NCCN Guidelines for Patients. Our supporters do not participate in the development of the NCCN Guidelines for Patients and are not
responsible for the content and recommendations contained therein.
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How to use this book

About multiple myeloma

NCCN Panel Members

NCCN Member Institutions

Offers tips to help you talk with your

Tests for myeloma

Describes the recommended tests to

Describes the types of treatments for

Presents the recommended course of

NCCN Guidelines for Patients

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About multiple myeloma

Genetic counseling | Treatment

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Who should read this book?

In this book, many medical words are included

Does the whole book

Words that you may not know are defined in the

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NCCN Guidelines for Patients

About multiple myeloma

Genetic counseling | Treatment

NCCN Guidelines for Patients

What are plasma cells?

How does multiple myeloma start?

What are M-proteins?

10 Symptoms of multiple myeloma

What are plasma cells?

Learning that you have cancer can

Blood is made of many types of cells, called blood

NCCN Guidelines for Patients

About multiple myeloma

What are plasma cells?

Plasma cells make antibodies. Antibodies (also called

Plasma cells also play an important role in the

Blood stem cell

NCCN Guidelines for Patients

About multiple myeloma

How does multiple myeloma start?

How does multiple myeloma

In contrast to plasma cells, myeloma cells make new

Multiple myeloma (also simply called myeloma) is a

When there is only one mass of myeloma cells, it

Genes are the instructions in cells for making new

NCCN Guidelines for Patients