Multiple myeloma, also known as myeloma, is a type of bone marrow cancer. Bone marrow is the spongy tissue at the centre of some bones that produces the body's blood cells.

It's called multiple myeloma as the cancer often affects several areas of the body, such as the spine, skull, pelvis and ribs.

Symptoms of multiple myeloma

In the early stages, myeloma may not cause any symptoms. It's often only suspected or diagnosed after a routine blood or urine test.

Eventually, myeloma causes a wide range of problems, including:

• a persistent bone pain, usually in the back, ribs or hips
• tiredness, weakness and shortness of breath – caused by anaemia
• high levels of calcium in the blood (hypercalcaemia) – which may cause symptoms including extreme thirst, stomach pain, needing to pee frequently, constipation or confusion
• weight loss
• blurred vision, dizziness or headaches – caused by thickened blood (hyperviscosity)
• repeated infections
• bruising and unusual bleeding – such as frequent nosebleeds, bleeding gums and heavy periods
• weak bones that break (fracture) easily – if this affects the spine, it might cause symptoms such as pins and needles, numbness and weakness in the legs and feet, and problems controlling your bladder and bowels, which requires emergency investigation
• kidney problems

Myeloma doesn't usually cause a lump or tumour. Instead, it damages the bones and affects the production of healthy blood cells.

When to see a GP

See a GP if you have any of the symptoms of multiple myeloma. While they're unlikely to be caused by cancer, it's best to get a proper diagnosis.

Your GP will examine you to check for bone tenderness, bleeding, signs of infection and any other symptoms that suggest you might have myeloma. They may also arrange blood and urine tests.

If myeloma is suspected, you'll be referred to a consultant haematologist (a specialist in blood conditions) for further tests and treatment.

Causes of multiple myeloma

It's not known exactly what causes multiple myeloma. However, there is a close link between multiple myeloma and a condition called monoclonal gammopathy of unknown significance (MGUS).

MGUS is where there is an excess of protein molecules, called immunoglobulins, in your blood. This doesn't cause any symptoms and doesn't need treatment.

Every year, around 1 in every 100 people with MGUS go on to develop multiple myeloma.

There is no known way to delay or prevent this, so people with MGUS will have regular tests to check for cancer.

Multiple myeloma is also more common in:

• men
• adults over 60 – most cases are diagnosed at around the age of 70, and cases affecting people under the age of 40 are rare
• black people – multiple myeloma is about twice as common in black populations than white and Asian populations
• people with a family history of MGUS or multiple myeloma

Treatment for multiple myeloma

Treatment can often help to control the condition for several years, but most cases of multiple myeloma can't be cured. Research is ongoing to try to find new treatments.

Treatment for multiple myeloma usually includes:

• anti-myeloma medicines to destroy the myeloma cells or control the cancer when it comes back (relapses)
• medicines and procedures to prevent and treat problems caused by myeloma – such as bone pain, fractures and anaemia

As part of your treatment, you may be asked if you want to take part in a clinical trial to help researchers develop better treatments for multiple myeloma.

Support groups for multiple myeloma

If you've been diagnosed with multiple myeloma, you may want to contact a local or national support group, such as Myeloma UK.

Your local haematology team will be able to direct you to helpful resources.

Support groups can offer more information and advice. They can also often put you in touch with other people in a similar situation so you can share advice and talk about your experiences.

Myeloma UK: help and support

Myeloma UK: find a local support group

Blood Cancer UK: blood cancer online community forum

Multiple myeloma may not cause any symptoms in the early stages but eventually leads to a wide range of problems. It's often diagnosed after a routine blood test or, sometimes, a urine test.

See a GP if you have any of the symptoms of multiple myeloma. While they're unlikely to be caused by cancer, it's best to be sure by getting a proper diagnosis.

Bone pain

Multiple myeloma can cause pain in affected bones – usually the back, ribs or hips.

The pain is frequently a persistent dull ache, which may be made worse by movement.

Bone fractures and spinal cord compression

Multiple myeloma can weaken the bones and make them more likely to break (fracture). The spine and long bones (arms and legs) are most often affected.

Fractures of the spine can cause the sections of the spine to collapse, leading to pain and, occasionally, compression of the spinal cord (the main column of nerves running down the back).

Compression of the spinal cord can cause:

• pins and needles
• numbness and weakness in the legs and feet
• problems controlling your bladder and bowels

You should seek immediate medical help if you have symptoms of spinal cord compression. It's an emergency and needs immediate investigation and treatment.

Anaemia

Multiple myeloma can affect the production of blood cells in the bone marrow, which can lead to a lack of red blood cells (anaemia). This can also occur as a side effect of myeloma treatment.

If you have anaemia, you may feel very tired, weak and breathless.

Repeated infections

People with multiple myeloma are particularly vulnerable to infection because the condition interferes with the immune system, the body's natural defence against infection and illness.

You may find you get frequent infections that last for a long time.

Raised calcium levels in the blood

A high level of calcium in the blood (hypercalcaemia) can develop in people with multiple myeloma because too much calcium is released from affected bones into the bloodstream.

Symptoms of hypercalcaemia can include:

• extreme thirst
• feeling sick
• stomach pain
• needing to urinate frequently
• constipation
• confusion and drowsiness

You should seek immediate medical help if you have symptoms of hypercalcaemia, as they need quick investigation and treatment.

Unusual bleeding

Some people with multiple myeloma have bruising and unusual bleeding (haemorrhage) – such as frequent nosebleeds, bleeding gums and heavy periods.

This is because the cancer cells in your bone marrow can stop blood-clotting cells called platelets from being made.

Thickened blood

In some people, multiple myeloma can cause the blood to become thicker than normal. This is due to the excess proteins that myeloma cells often produce.

This is known as hyperviscosity and can cause problems such as:

• blurred vision
• headaches
• dizziness
• bleeding from the gums or nose
• shortness of breath

Kidney problems

Kidney damage can occur in people with multiple myeloma. Eventually, the kidneys may stop working properly.

This is known as kidney or renal impairment, or kidney or renal failure.

Signs of kidney failure can include:

• weight loss and poor appetite
• swollen ankles, feet or hands
• tiredness and a lack of energy
• shortness of breath
• itchy skin
• feeling sick
• hiccups that won't go away

You should seek immediate medical help if you have symptoms of kidney failure. It's an emergency and needs quick investigation and treatment.

Multiple myeloma can be difficult to diagnose because it's an uncommon type of cancer that usually has few or no symptoms in the early stages.

What happens at your GP appointment

Your GP will examine you and ask about your symptoms, medical history and overall health.

During the examination, your GP will look for things such as bleeding, signs of infection and specific areas of bone tenderness.

You may need urine and blood tests to check for certain types of antibodies and proteins (immunoglobulins).

Referral to hospital

If multiple myeloma is suspected, you'll be referred to hospital to see a haematologist (a doctor who specialises in conditions affecting the blood) for further tests and scans.

MRI and CT scans

In hospital you are likely to have CT scans and MRI scans taken of your arms, legs, skull, spine and pelvis to look for any damage.

It's likely you will also need other scans, such as CT scans and MRI scans.

Bone marrow biopsy

A bone marrow biopsy is usually needed to confirm multiple myeloma.

A needle is used to take a small sample of bone marrow (where all the blood cells are made) from one of your bones, usually the pelvis.

A small sample of bone may also be removed.

This is carried out using a local anaesthetic, which means the area where the needle is inserted is numbed.

The samples of bone marrow and bone will then be checked for cancerous plasma cells.

Treatment for multiple myeloma can often help to control symptoms and improve quality of life. But myeloma usually can't be cured. This means additional treatment is needed when the cancer comes back.

Not everyone diagnosed with myeloma needs immediate treatment – for example, the condition may not be causing any problems. This is sometimes referred to as asymptomatic or smouldering myeloma.

Find out more about smouldering myeloma on the Myeloma UK website.

If you don't need treatment, you'll be monitored for signs the cancer is beginning to cause problems.

If you do need treatment, the most commonly used options are outlined below.

Discussing your multiple myeloma treatment

If you have multiple myeloma, you'll be cared for by a team, which is usually led by a consultant haematologist who specialises in myeloma.

The team will discuss your condition and recommend the best treatment for you. However, the final decision to begin treatment will be yours.

Before visiting hospital to discuss your treatment options, it may be useful to write a list of questions to ask the specialist.

For example, you may want to find out the advantages and disadvantages of a particular treatment.

Bringing myeloma under control

The initial treatment for multiple myeloma may be either:

• non-intensive – for older or less fit patients (this is more common)
• intensive – for younger or fitter patients

Both non-intensive and intensive treatments involve taking a combination of anti-myeloma medicines.

But intensive treatment involves higher doses and is followed by a stem cell transplant.

The medicines usually include a chemotherapy medicine, a steroid medicine, and either thalidomide or bortezomib.

Chemotherapy

Chemotherapy medicines kill the myeloma cells. A number of treatments are often combined to treat multiple myeloma.

These treatments are often taken in tablet form. Side effects are usually mild but may include:

• increased risk of infections
• feeling sick
• vomiting
• hair loss
• damage to nerves (neuropathy)

Your clinician will give you advice and information about your risk of developing potentially serious infections. They'll also tell you what you can do to reduce your risk.

Steroids

Corticosteroids help destroy myeloma cells and make chemotherapy more effective. The most common types used to treat myeloma are dexamethasone and prednisolone.

Steroids are taken by mouth after eating. Possible side effects include:

• heartburn
• indigestion
• increased appetite
• mood changes
• problems sleeping (insomnia)

Thalidomide

Thalidomide can help kill myeloma cells. You take it as a tablet every day – usually in the evening, as it can make you feel sleepy.

Other common side effects include:

• constipation
• dizziness
• rashes
• numbness or tingling in the hands and feet (peripheral neuropathy)

Thalidomide can cause birth defects, so should not be taken by pregnant women, and a reliable form of contraception such as a condom must be used during treatment.

There is also a risk you may develop a blood clot when taking thalidomide, so you may be given medication to help prevent this.

Contact your care team immediately if you develop symptoms of a blood clot, such as pain or swelling in one of your legs, or chest pain and breathlessness.

Myeloma UK: thalidomide treatment guide

Bortezomib

Bortezomib (Velcade) can help kill myeloma cells by causing protein to build up inside them.

There are some limitations as to who can have bortezomib, but a member of your care team will discuss this with you.

The medication is given by injection, usually under the skin. Possible side effects include:

• tiredness
• diarrhoea
• numbness or tingling in your hands and feet (peripheral neuropathy)

Myeloma UK: bortezomib treatment guide

Stem cell transplant

People receiving intensive treatment are given a much higher dose of chemotherapy medication as an inpatient to help destroy a larger number of myeloma cells.

This aims to achieve a longer period of remission (where there is no sign of active disease in your body) but does not result in a cure.

However, these high doses also affect healthy bone marrow, so a stem cell transplant will be needed to allow your bone marrow to recover.

In most cases, the stem cells will be collected from you before you are admitted for the high-dose treatment. This is called an autologous transplant.

In very rare cases, they are collected from a sibling or unrelated donor.

If you have an autologous transplant soon after being diagnosed, you may also need to take a medicine called lenalidomide. Lenalidomide helps prevent your symptoms from getting worse or returning.

Treating relapses

Further treatment is needed if myeloma returns. Treatment for relapses is similar to initial treatment, although non-intensive treatment is often preferred.

A small group of people may benefit from a second course of high-dose treatment, which your haematologist would discuss with you.

Additional medicines – such as lenalidomide, pomalidomide, carfilzomib and daratumumab – and other chemotherapy medicines may also be given.

You will also have a stem cell transplant if the first transplant worked well.

You may also be asked if you want to participate in clinical trial research into new treatments for multiple myeloma.

Lenalidomide and pomalidomide

Lenalidomide and pomalidomide are similar to thalidomide.

They're both taken by mouth and can affect the cells produced by your bone marrow, which can cause:

• increased risk of infection – as a result of a low number of white blood cells
• anaemia – caused by a low number of red blood cells
• bruising and bleeding – because of a low platelet count

They may also increase your risk of developing a blood clot and have other side effects similar to thalidomide.

Let your care team know if you experience any problems or unusual symptoms while taking lenalidomide or pomalidomide.

Myeloma UK: lenalidomide treatment guide

Myeloma UK: pomalidomide treatment guide

Carfilzomib

Carfilzomib is a medication similar to bortezomib.

However, unlike bortezomib, it's given on a regular basis as a long-term treatment.

It's also given as an injection into the veins (intravenous) rather than under the skin (subcutaneous).

Carfilzomib is a more intensive treatment than bortezomib.

Possible side effects include kidney and heart problems and, less commonly, nerve damage.

Carfilzomib can be taken with dexamethasone and lenalidomide. But only if you’ve had 1 previous treatment that included bortezomib.

Your haematologist will give you advice about which treatment is best for you.

Myeloma UK: carfilzomib treatment guide

Daratumumab

Daratumumab is a new antibody treatment available in the UK for treating myeloma when it has come back a number of times.

It targets one of the proteins on myeloma cells called CD38 and helps kill the cancerous myeloma cells.

Daratumumab is given as an intravenous drip on a long-term, regular basis.

Your haematologist will discuss the possible side effects with you, but most people tolerate it very well.

However, the first dose often causes an allergic reaction, which will mean an overnight stay in hospital.

There is also a risk that daratumumab can cause the hepatitis B virus to come back in people who have had the virus before.

This is serious and your haematologist will test you for hepatitis B before prescribing this drug.

Myeloma UK: daratumumab treatment guide

Ixazomib

Ixazomib citrate (Ninlaro, Takeda) is used to treat multiple myeloma in adults who have had at least 1 other therapy.

Ixazomib is given as a tablet once a week on days 1, 8, and 15 of a 28-day treatment cycle, and is taken alongside lenalidomide and dexamethasone.

Myeloma UK: treatment for relapsed myeloma

Isatuximab

Isatuximab is a new antibody treatment that is used to treat multiple myeloma in adults where 3 other treatments have not worked.

It's taken with pomalidomide and dexamethasone, and is in the same group of medicines as daratumumab.

Isatuximab is given as an intravenous drip on a long-term, regular basis.

It has many possible side effects, including infections, a high temperature, diarrhoea and feeling sick, but each person is different.

Myeloma UK: isatuximab treatment guide

Panobinostat

Panobinostat is a newer treatment for multiple myeloma. It's given as a tablet over a few months, alongside bortezomib and a steroid tablet.

Its main side effects include diarrhoea, fatigue and low blood counts.

It can occasionally cause heart problems, but your haematologist will discuss the possible side effects with you.

Myeloma UK: panobinostat.treatment guide

Treating symptoms and complications of myeloma

As well as the main treatments for multiple myeloma, you may also need treatment to help relieve some of the problems caused by the condition.

For example:

• painkillers – to reduce pain
• radiotherapy – to relieve bone pain or help healing after a bone is surgically repaired
• bisphosphonate medicine given as tablets or by injection – to help prevent bone damage and reduce the levels of calcium in your blood
• blood transfusions or erythropoietin medication – to increase your red blood cell count and treat anaemia
• surgery – to repair or strengthen damaged bones, or treat compression of the spinal cord (the main column of nerves running down the back)
• dialysis – may be required if you develop kidney failure
• plasma exchange – treatment to remove and replace the liquid that makes up blood (plasma), if you have unusually thick blood

These treatments can each cause side effects and complications. Make sure you discuss the potential risks and benefits with your treatment team.

Clinical trials and research

Research is ongoing to find new treatments for multiple myeloma and work out ways to improve the use of existing ones.

To help with this, you may be asked to take part in a clinical trial during your treatment.

Clinical trials usually involve comparing a new treatment with an existing one to see whether the new treatment is more or less effective.

It's important to remember that if you are given a new treatment, there's no guarantee it will be more effective than an existing treatment.

There will never be any pressure for you to take part in a trial if you don't want to.

Myeloma UK: clinical trials