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INFORMATION FOR PATIENTSUpToDate offers two types of patient education materials,

"The Basics" and "Beyond the Basics." The Basics patient education pieces are written in
plain language, at the 5th to 6th grade reading level, and they answer the four or ve key
questions a patient might have about a given condition. These articles are best for patients
who want a general overview and who prefer short, easy-to-read materials. Beyond the
Basics patient education pieces are longer, more sophisticated, and more detailed. These
articles are written at the 10th to 12th grade reading level and are best for patients who want
in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Multiple myeloma (The Basics)")

Beyond the Basics topics (see "Patient education: Multiple myeloma symptoms,
diagnosis, and staging (Beyond the Basics)" and "Patient education: Multiple myeloma
treatment (Beyond the Basics)" and "Patient education: Hematopoietic cell
transplantation (bone marrow transplantation) (Beyond the Basics)")


Verication of the diagnosis Patients with multiple myeloma (MM) should be

distinguished from patients with monoclonal gammopathy of undetermined signicance
(MGUS) and smoldering multiple myeloma (SMM) who do not need therapy (table 1 and
algorithm 1). (See 'Verication of the diagnosis' above and "Clinical features, laboratory
manifestations, and diagnosis of multiple myeloma", section on 'Diagnosis'.)

Among patients with SMM, we recommend deferral of chemotherapy until disease

progression (Grade 1B).

Patients who have end-organ damage attributable to the underlying plasma cell
disorder have MM and require therapy. The following ndings, if attributable to the
underlying plasma cell disorder, are clear indications for treatment: anemia,
hypercalcemia, renal insufciency, lytic bone lesions or severe osteopenia, and
extramedullary plasmacytoma (excluding solitary extramedullary plasmacytoma).

Otherwise asymptomatic patients who have one of the following biomarkers are
also considered to have MM and require therapy: 60 percent clonal plasma cells in
the marrow; involved/uninvolved free light chain (FLC) ratio of 100 or more; or more
than one focal bone lesion on MRI.
Among patients with MM as dened above, we recommend prompt initiation of
treatment (Grade 1B).

Risk stratication Patients with MM are stratied at the time of diagnosis into three
main risk categories (standard risk, intermediate risk, and high risk) (table 4). This risk
stratication has considerable prognostic value and also helps guide the selection of
initial therapy (algorithm 2). (See 'Risk stratication' above.)

Patients with t(14;16), t(14;20), or del17p13 by FISH are considered to have high-risk
myeloma. Patients with lactate dehydrogenase (LDH) 2 times the institutional upper
limit of normal and those with features of primary plasma cell leukemia are also
considered to have high-risk MM. Patients with t(4;14) or 1q+ by FISH or deletion
13/hypodiploidy are considered to have intermediate-risk MM. All other patients with
MM who lack any of the high- or intermediate-risk cytogenetic abnormalities or features
are considered to have standard-risk MM; this includes patients with trisomies, t(11;14)
and t(6;14).

Determining transplant eligibility High-dose chemotherapy with autologous

hematopoietic cell transplantation (HCT) is the preferred therapy for patients with
standard- or intermediate-risk myeloma. Eligibility for HCT in MM varies across
countries and across institutions. Although guidelines are provided, the decision on
transplant eligibility should be made based on a risk-benet assessment and the needs
and wishes of the patient. Patients eligible for HCT receive induction therapy for two to
four months prior to stem cell collection in order to reduce the number of tumor cells in
the bone marrow and peripheral blood, lessen symptoms, and mitigate end-organ
damage. During this time, specic arrangements for the subsequent HCT can be made
to ease the transition of therapy. (See 'Determining transplant eligibility' above.)

Approach to therapy in standard- and intermediate-risk myeloma Using information

gathered from the risk stratication and HCT eligibility assessment, a general plan of
care can be determined:

For patients with standard or intermediate-risk MM who are candidates for HCT, we
recommend the use of induction therapy for two to four months followed by
autologous HCT rather than either conventional chemotherapy alone (Grade 1B) or
myeloablative allogeneic HCT (Grade 1A).

We suggest that patients proceed with their rst HCT after recovery from stem cell
collection (early transplant) (Grade 2A), although survival may not be signicantly
different between early versus delayed HCT, particularly in patients with standard-
risk myeloma. Timing of HCT is discussed in detail separately. (See "Autologous
hematopoietic cell transplantation in multiple myeloma", section on 'Timing of

The preferred induction chemotherapy regimen depends on the risk stratication.

The multiple treatment regimens available for these patient populations are
discussed in more detail separately. (See "Selection of initial chemotherapy for
symptomatic multiple myeloma".)

Patients ineligible for HCT receiving induction lenalidomide plus dexamethasone

generally continue treatment until progression unless there is signicant toxicity. In
contrast, those receiving alkylator or bortezomib-based triplet regimen are treated
for approximately 12 to 18 months and then observed until progression. (See
'Duration of initial therapy' above.)

High-risk myeloma Patients with high-risk MM should be encouraged to enroll in a

clinical trial investigating novel therapeutic strategies, since they do poorly with all
conventional treatment options. (See "Selection of initial chemotherapy for symptomatic
multiple myeloma", section on 'High-risk myeloma'.)

Complementary therapy All patients with MM should be encouraged to be as active as

possible in order to maintain bone density while avoiding activities with an excessive
risk of trauma. Patients with one or more lesions on skeletal radiographs and those with
osteopenia should be given bisphosphonate therapy, which signicantly reduces the
number of skeletal events. Pneumococcal and inuenza vaccine should also be given to
all patients. In addition, patients with MM frequently develop complications related to
their disease, including hypercalcemia, renal insufciency, infection, and skeletal lesions,
which require specic treatment in addition to therapy directed at the malignant clone.
(See "The use of osteoclast inhibitors in patients with multiple myeloma" and "Treatment
of the complications of multiple myeloma".)

Evaluating response Patients should be evaluated before each treatment cycle to

determine how their disease is responding to therapy (table 7). Details on how to
determine response to therapy are presented separately. (See "Evaluating response to
treatment of multiple myeloma".)

Relapsed disease Almost all patients with MM who survive initial treatment will
eventually relapse and require further therapy. Relapsed or refractory MM is usually
identied on routine surveillance performed during treatment or after the completion of
therapy. Treatment options for patients with relapsed or refractory MM include HCT, a
rechallenge of the previous chemotherapy regimen, or a trial of a new regimen. (See
'Relapsed disease' above.)