Multiple myeloma is a blood cancer that starts in plasma cells, the cells in the bone marrow that normally make antibodies. Treatment depends on whether the myeloma is active, how it is affecting the bones or kidneys, the genetic findings, and how much treatment the patient is likely to tolerate. Most patients with active myeloma start with a combination of medicines. For eligible patients, an autologous stem cell transplant may be part of the first treatment plan. [1–3]
By Dr Raman Narang, Consultant Medical & Hemato-Oncologist, New Delhi
An abnormal protein on a blood test can lead to three different conversations. One person may need occasional monitoring for MGUS. Another may have smouldering myeloma and need a closer look at the risk of progression. A third may need treatment promptly because active myeloma is affecting kidney function. If you are seeking multiple myeloma treatment in Delhi, the first question to ask is which category your results fit and what finding determines the urgency of treatment.
1. What are the symptoms of multiple myeloma?
Myeloma can weaken bones, interfere with normal blood cell production, and affect kidney function. Symptoms can include persistent back or rib pain, fractures after a minor injury, fatigue or breathlessness from anaemia, and repeated infections. High calcium levels can cause thirst, constipation, weakness, or confusion. Some patients first come to attention because a routine blood test shows anaemia, an abnormal protein level, or a decline in kidney function. [1, 2]
These symptoms have several possible causes. New severe back pain with leg weakness, numbness, or loss of bladder or bowel control needs emergency evaluation because it can indicate pressure on the spinal cord or nearby nerves. A marked drop in urine output, new confusion, or fever during treatment also warrants urgent medical assessment. [1, 2]
2. What is the difference between MGUS, smouldering myeloma, and active myeloma?
The team looks at how many abnormal plasma cells are present, how much abnormal protein they produce, and whether they are causing harm or meet a defined threshold for starting treatment. A single protein result rarely answers all of those questions. [1–3]
| Finding | What it usually means for care |
|---|---|
| MGUS | Monoclonal gammopathy of undetermined significance. A small population of abnormal cells produces a detectable protein without meeting the criteria for myeloma. Follow-up depends on the risk of progression. |
| Smouldering multiple myeloma | There is a greater burden of abnormal plasma cells or protein than in MGUS, but no myeloma-defining event. The team estimates the risk of progression and plans follow-up. For selected patients with high-risk smouldering myeloma, early treatment may be discussed. |
| Active multiple myeloma | The combination of abnormal plasma cells and one or more myeloma-defining events meets the criteria for treatment. Kidney injury or other complications can make the decision urgent. |
| Solitary plasmacytoma | A single tumour of plasma cells in bone or soft tissue. Further testing checks whether the disease is truly localised. If it is, focused radiation is often the main treatment. |
You may hear the terms CRAB and SLiM. CRAB refers to high calcium, renal impairment, anaemia, or bone damage attributable to the plasma cell disorder. SLiM refers to specific findings on bone marrow testing, free light chain testing, or MRI that can justify treatment before those complications develop. [1, 2]
For eligible adults with high-risk smouldering myeloma, the US FDA approved a subcutaneous form of daratumumabbased on the AQUILA trial. The decision to treat depends on how high risk was established, the expected benefits and side effects, and the applicable Indian prescribing indication and access. [3, 4]
3. How is multiple myeloma diagnosed and risk-assessed?
The diagnosis uses blood and urine tests, a bone marrow sample, and imaging. Each answers a different question. [1, 2]
| Test | What it helps the team determine |
|---|---|
| Blood count, creatinine, and calcium | Whether there is anaemia, kidney impairment, or high calcium that may be related to myeloma. |
| Protein electrophoresis, immunofixation, and serum free light chains | The type and amount of abnormal protein. Some patients mainly produce light chains, so a small or absent M-spike on electrophoresis can miss part of the picture. Urine testing can provide additional information. |
| Bone marrow aspiration and biopsy | How many abnormal plasma cells are present. A genetic test called FISH looks for changes that can affect risk and treatment planning. |
| Whole-body low-dose CT, PET-CT, or MRI | Whether there are areas of bone damage or marrow involvement. The choice depends on the question the team needs to answer. |
Myeloma staging works differently from staging a solid tumour. Systems such as the Revised Second International Staging System (R2-ISS) use blood markers and selected genetic findings to estimate risk. Findings such as deletion 17por additional copies of chromosome 1q can affect the assessment. Stage informs the treatment discussion alongside frailty, kidney function, and response to treatment. [1, 2]
4. How is newly diagnosed multiple myeloma treated?
The first phase, called induction, aims to bring the myeloma under control and protect affected organs. A common approach for patients who can tolerate it combines a CD38-targeted antibody with bortezomib, lenalidomide, and dexamethasone. The regimen and doses are adjusted for factors such as kidney function, nerve symptoms, infection risk, frailty, and treatment access. [2, 3]
| Clinical situation | What the team usually discusses |
|---|---|
| Eligible for an autologous stem cell transplant | Induction treatment, collection of the patient’s own stem cells, high-dose treatment followed by return of those cells, and ongoing maintenance. |
| Transplant is unsuitable or deferred | A drug combination that fits the patient’s health and priorities. A fit patient may tolerate four drugs, while a frailer patient may benefit from a simpler or dose-adjusted regimen. |
| Myeloma is causing acute kidney injury | Prompt treatment to reduce the abnormal light chains and protect kidney function. A bortezomib-based regimen is often considered, alongside management of other factors that may be worsening the kidney injury. |
How is transplant eligibility decided? Age is one part of the assessment. The team also considers daily functioning, heart and lung health, other illnesses, and the likely benefits and complications of high-dose treatment. An autologous transplant uses your own stem cells, so a donor is unnecessary. For eligible patients, it can extend the time the myeloma stays controlled. Maintenance treatment, often based on lenalidomide after transplant, aims to keep the disease controlled for longer. [2, 3]
Supportive care begins alongside myeloma treatment. It can include bone-strengthening medicines when suitable, pain management, measures to lower infection and blood clot risk, and assessment of fracture risk. Focused radiation or orthopaedic surgery may help with selected painful or unstable bone lesions. [1, 2]
5. How is relapsed or treatment-resistant myeloma treated?
Relapsed myeloma has returned or progressed after a response. Refractory myeloma is resistant to a treatment or progresses soon after it. The next choice depends on which medicines have already been used, which ones the myeloma resisted, how long the response lasted, and whether the relapse is affecting organs or causing symptoms. The team interprets a rising protein or light chain level alongside the trend over time, other blood tests, symptoms, and imaging where appropriate. [1–3]
Options may include a new combination of antibody therapy, a proteasome inhibitor, or an immunomodulatory medicine. For eligible patients, CAR T-cell therapy or bispecific antibodies may also be considered. These approaches direct immune cells against myeloma cells and require specialist assessment because they can cause significant side effects, including infections. Prior treatment, fitness, the locally applicable indication, and access help determine when they fit. [2, 3]
What I look for clinically before recommending treatment
I start by asking whether the myeloma is already affecting the kidneys, bones, or blood counts. I review the bone marrow, FISH, and imaging together, then assess how well the patient is managing daily activities. If transplant is an option, I discuss it early because it affects stem cell collection and treatment planning. I also agree on which result we will follow to judge response. That may be the M-protein, free light chains, or another measure that reflects the patient’s disease.
How the next step is decided
| If the reports show… | The next discussion is about… |
|---|---|
| An abnormal protein without a confirmed diagnosis | Whether further blood tests, imaging, or a bone marrow biopsy are needed |
| Smouldering myeloma | Risk of progression, monitoring frequency, and whether early treatment is appropriate |
| Active myeloma with worsening kidney function | How quickly treatment should begin and what can help protect the kidneys |
| Newly diagnosed active myeloma in a patient fit for transplant | Induction, stem cell collection, transplant timing, and maintenance |
| Myeloma returning after treatment | Which medicines the disease is resistant to and which options remain suitable |
What to bring to a myeloma consultation in Delhi
- Recent and previous blood counts, creatinine, calcium, and albumin results.
- Serum protein electrophoresis, immunofixation, free light chain, and urine protein reports, if available.
- Bone marrow aspiration and biopsy reports, including FISH or cytogenetic results.
- CT, PET-CT, or MRI reports and the original scan images.
- A list of prior treatments with dates, responses, and significant side effects.
- A note of recent infections, fractures, changes in mobility, and other medical conditions.
Frequently asked questions
Does an M-protein mean I have multiple myeloma?
An M-protein can occur in MGUS, smouldering myeloma, or active myeloma. The diagnosis depends on the amount and type of protein, the bone marrow findings, and whether there is organ damage or another myeloma-defining event. [1, 2]
Does everyone with myeloma need a stem cell transplant?
Transplant is one option for eligible patients. Many people receive effective drug treatment without a transplant. The decision depends on fitness, treatment goals, and individual preferences. [2, 3]
Can kidney function improve after myeloma treatment?
It can improve in some patients, particularly when treatment promptly reduces the abnormal light chains and other causes of kidney injury are addressed. Recovery depends on the cause, severity, and duration of the injury. [1, 2]
Can multiple myeloma be cured?
Treatment usually aims for long-term control and prevention of organ damage. Many patients achieve remission, and the team continues to monitor for changes that may require further treatment. [1–3]
At your consultation, ask for the exact diagnosis, the reason treatment is or is not needed now, and the test that will show whether the plan is working. If transplant or maintenance is being considered, ask how it fits into the full treatment course.
This page is for general education. Individual treatment decisions require review of your blood tests, bone marrow findings, imaging, and overall health by your treating team.
Clinical references
- International Myeloma Working Group. Updated Criteria for the Diagnosis of Multiple Myeloma. Lancet Oncology, 2014.
- European Hematology Association and European Myeloma Network. EHA–EMN Evidence-Based Guidelines for Diagnosis, Treatment and Follow-up of Patients With Multiple Myeloma. 2025.
- American Society of Clinical Oncology. Treatment of Multiple Myeloma: ASCO Living Guideline. Version 2026.1.3.
- US Food and Drug Administration. FDA Approves Daratumumab and Hyaluronidase-fihj for High-Risk Smoldering Multiple Myeloma. November 2025.