Multiple myeloma

Multiple myeloma, also known as myeloma, is a type of bone marrow cancer.

Bone marrow is the spongy tissue found at the centre of some bones. It produces the body's blood cells. Multiple myeloma affects the plasma cells (a type of blood cell) inside the bone marrow.

Myeloma does not usually take the form of a lump or tumour. Instead, the myeloma cells divide and expand within the bone marrow, damaging the bones and affecting the production of healthy blood cells.

Myeloma often affects many places in the body, which is why it is called multiple myeloma. Commonly affected areas include the spine, skull, pelvis and ribs.

Signs and symptoms

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

However, myeloma will eventually cause a wide range of problems, including:

• a persistent dull ache or specific areas of tenderness in your bones
• weak bones that break (fracture) easily
• tiredness, weakness and shortness of breath (caused by anaemia)
• repeated infections
• less commonly, bruising and unusual bleeding – such as frequent nosebleeds, bleeding gums and heavy periods

Read more about the symptoms of multiple myeloma

When to speak to your GP

Speak to your GP if you have any of these symptoms. 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 may have myeloma.

They may also arrange blood and urine tests that can detect abnormal proteins produced by myeloma cells.

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

Read more about diagnosing multiple myeloma

Who is affected?

Multiple myeloma is an uncommon type of cancer.

It's not known exactly what causes the condition, although it's more common in:

• people with monoclonal gammopathy of unknown significance (MGUS) – an excess number of protein molecules called immunoglobulins in your blood
• 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 compared with white and Asian populations

Read more about the causes of multiple myeloma.

How multiple myeloma is treated

There is currently no cure for multiple myeloma, but treatment can often help control it for several years.

Treatment will often involve:

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

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.

Read more about treating multiple myeloma

Support groups

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

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.

The Myeloma UK website has more information about how they can help you and finding a local support group.

In the early stages, multiple myeloma may not cause any symptoms or complications, and may only be diagnosed after a routine blood or urine test.

However, it will eventually cause a wide range of problems.

Bone pain

Multiple myeloma can cause pain in affected bones, most often 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 ribs 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, and sometimes problems controlling your bladder and bowels.

Anaemia

Multiple myeloma can affect the production of blood cells in our 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 infections frequently and that they 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, needing to urinate frequently, constipation, confusion and drowsiness.

Unusual bleeding

Bruising and unusual bleeding (haemorrhage) – such as frequent nosebleeds, bleeding gums and heavy periods – sometimes occurs in multiple myeloma because the cancer cells in your bone marrow can stop blood clotting cells called platelets being made.

Thickened blood

In some people, multiple myeloma can cause the blood to become thicker than normal. This is known as hyperviscosity, which can cause problems such as blurred vision, headaches, dizziness, bleeding from the gums or nose, and shortness of breath.

Kidney problems

Kidney damage can occur in people with multiple myeloma for several reasons. Abnormal proteins produced by the cancer cells can damage the kidneys, as can other complications, such as hypercalcaemia. Some medications used to treat multiple myeloma can also cause kidney damage.

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

When to seek medical advice

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

You should seek immediate medical help if you have symptoms of spinal cord compression, hypercalcaemia or kidney failure, as these are medical emergencies that need to be investigated and treated as soon as possible.

Read more about diagnosing multiple myeloma and treating multiple myeloma

In multiple myeloma, cells inside the bone marrow called plasma cells become cancerous.

Bone marrow is the spongy tissue found at the centre of some bones. It produces the body's blood cells.

Plasma cells are normally produced in a controlled way. In cases of multiple myeloma, large numbers of abnormal plasma cells are produced. These fill up the bone marrow and interfere with the production of other cells, such as red and white blood cells.

The exact reason why this happens is unknown, but multiple myeloma is closely associated with a condition called monoclonal gammopathy of unknown significance (MGUS), and there are certain things that can increase your risk of developing it.

Monoclonal gammopathy of unknown significance (MGUS)

In almost all cases, multiple myeloma occurs in someone who previously had MGUS.

MGUS is the name for having an excess number of protein molecules called immunoglobulins in your blood. This does not cause any symptoms and treatment is not required.

However, 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 ongoing outpatient tests to check for cancer will usually be recommended if you have MGUS.

Other factors

As well as MGUS, certain things can increase your risk of developing multiple myeloma, including:

• age – your risk of developing multiple myeloma increases as you get older; most cases are diagnosed at around the age of 70, and cases affecting people under 40 are rare
• gender – men are more likely to develop multiple myeloma than women
• ethnicity – multiple myeloma is about twice as common in black populations compared with white and Asian populations

It has also been suggested that having a family history of MGUS or multiple myeloma, having reduced immunity (for example, because of medication or HIV), being overweight or obese, and being exposed to radiation or certain chemicals may increase your risk of multiple myeloma. However, a link between these factors and the condition is less clear.

Multiple myeloma can be difficult to diagnose because it's an uncommon type of cancer that initially has few or no symptoms.

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).

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

Blood tests

A number of blood tests are used to help diagnose multiple myeloma, and they may need to be repeated to monitor the condition.

These may include:

• erythrocyte sedimentation rate (ESR) or plasma viscosity (PV) – if you have multiple myeloma, your ESR or PV will usually be raised
• tests to measure the type and number of abnormal antibodies produced by the cancerous plasma cells
• a full blood count (FBC) to check levels of different types of blood cells – your doctor will be looking for a low number of red blood cells and platelets
• liver and kidney function
• blood calcium level

Urine tests

A urine sample will be checked for the abnormal proteins produced by the cancerous plasma cells. The abnormal proteins are known as monoclonal light chains, or Bence Jones protein.

These proteins can damage your kidneys as they pass through them from your blood to your urine. You may be asked to collect your urine over a 24-hour period. This will be used to check the quantity of proteins being produced and how well your kidneys are working.

X-rays and other scans

You will have X-rays taken of your long bones (arms and legs), skull, spine and pelvis to look for any damage.

Other scans, such as computerised tomography (CT) scans and magnetic resonance imaging (MRI) scans, may also be carried out.

Bone marrow biopsy

A bone marrow biopsy is usually needed to confirm multiple myeloma. A needle will be used to take a small sample of bone marrow from one of your bones, usually the pelvis. A sample of bone may also be removed.

This is carried out using a local anaesthetic (the area where the needle is inserted is numbed).

The sample of bone marrow and bone will be used to check for cancerous plasma cells.

If you have multiple myeloma, you will 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 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.

There are 2 main aims in treating multiple myeloma:

• to bring the myeloma under control
• to prevent and treat problems associated with myeloma, such as anaemia and bone pain

While treatment can often control myeloma and improve quality of life, myeloma usually can't be cured. This means additional treatment is needed when the cancer comes back (a relapse).

Not everyone diagnosed with myeloma will need immediate treatment if the condition is not causing any problems. This is sometimes referred to as asymptomatic, or smouldering myeloma.

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 following options are most commonly used.

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 (thought to be too toxic for older or less fit patients)

The decision about which treatment is appropriate for you is usually based on your biological age or fitness.

As a general rule, people younger than 65 are more likely to be candidates for intensive therapy. For those over 70, non-intensive treatment is more likely to be recommended.

Those aged in between will be given careful consideration as to what treatment group they fall into.

Both non-intensive and intensive treatments involve taking a combination of anti-myeloma medicines. Intensive treatment involves much 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. The most common types used to treat myeloma are melphalan and cyclophosphamide.

These treatments are mostly taken in tablet form. They are reasonably well tolerated and side effects are mild. Possible side effects include:

• increased risk of infections
• feeling sick
• vomiting
• hair loss

Your clinician will give you advice and information about your risk of developing potentially serious infections, and tell you what you can do to reduce your risk of picking up infections during your treatment.

Steroids

Steroid medications (corticosteroids) help destroy myeloma cells and make chemotherapy more effective. The 2 most common types used to treat myeloma are dexamethasone and prednisolone.

Steroids are taken orally (by mouth) after eating. Possible side effects include heartburn, indigestion, increased appetite, mood changes and problems falling asleep.

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 it 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.

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

Stem cell transplant

After initial therapy with primarily outpatient-based treatments, people receiving intensive treatment will be given a much higher dose of chemotherapy medication as an inpatient to potentially 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).

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

In most cases, the stem cells will be collected from you before treatment (autologous transplantation). In rare cases, they are collected from a sibling or an unrelated donor.

Treating relapses

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

Additional medications such as lenalidomide, pomalidomide and other chemotherapy medicines may be added, or used again as your haematologist feels is appropriate.

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 both can have an effect on 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.

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 – may be given to reduce pain
• radiotherapy – may be used to relieve bone pain or help healing after a bone is surgically repaired
• bisphosphonate medication – either given as tablets or by injection, this may help prevent bone damage and reduce the levels of calcium in your blood
• blood transfusions or erythropoietin medication – may be used to increase your red blood cell count and treat anaemia
• surgery – may be carried out 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 a blood component called plasma may be carried out if you have unusually thick blood (hyperviscosity)

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

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, however, that if you are given a new treatment, there is 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 do not want to.

Search clinical trials for multiple myeloma