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Stages

Here you'll find information on stages and the treatment options for myeloma. 

The stage of a cancer tells your doctor how far it has grown or spread. It helps them decide which treatment you need.

The International Staging System

Doctors use the International Staging System (ISS) to stage myeloma. It looks at the results of 2 blood tests. These blood tests are ß2-microglobulin and albumin. Doctors use this system to help them predict how you might respond to treatment. 

The ISS divides myeloma into 3 stages:

Stage 1 means:

  • the level of the protein called beta 2 microglobulin (ß2-microglobulin or ß2-M) is less than 3.5 milligrams per litre (mg/L)​
  • the level of albumin in the blood is more than 3.5 grams per decilitre (g/dL)

Stage 2 means:

  • the level of ß2-M is between 3.5 and 5.5 mg/L, with any albumin level OR
  • the level of ß2-M is less than 3.5 mg/L and the level of albumin is less than 3.5 g/dL 

Stage 3 means:

  • the level of ß2-M is more than 5.5 mg/L 

How doctors classify myeloma

Doctors simplify the way they classify myeloma to help them know which myeloma treatment you need. To do this they look at whether your myeloma is affecting your body tissues and organs, and causing symptoms. The symptoms they check for are called CRAB, which stands for:

  • calcium (high levels)
  • renal (kidney damage)
  • anaemia (low levels of red blood cells)
  • bone damage

Doctors then group you as having either:

  • asymptomatic myeloma – myeloma without symptoms
  • symptomatic myeloma – myeloma with symptoms

Myeloma without symptoms (asymptomatic myeloma)

Asymptomatic myeloma is also called smouldering or indolent myeloma. This means you don't have symptoms but have:

  • a level of paraprotein in your blood that is more than 30 g/L
  • a level of abnormal plasma cells in your bone marrow that is between 10% and 60%
  • no related organ or tissue damage

You do not normally have treatment for asymptomatic myeloma. But your doctor will want to monitor you at least every 3 months for any symptoms. Asymptomatic myeloma eventually progresses to symptomatic myeloma, but your doctor cannot say when this will happen. The risk of progression is highest in the first 5 years. 

Overall, 10 out of 100 people with asymptomatic myeloma (10%) develop symptomatic myeloma every year for the first 5 years. About 3 out of 100 people (3%) develop symptomatic myeloma every year for the next 5 years. And 1 out of 100 people (1%) develop symptomatic myeloma every year after that.

Myeloma with symptoms (symptomatic myeloma)

If you have symptomatic myeloma you need to have treatment. Symptomatic myeloma means you have:

  • abnormal plasma cells in your bone marrow,
  • an area of abnormal plasma cells in your bone or soft tissue (plasmacytoma)
  • damage to tissues or organs (such as bone problems, high calcium levels, kidney problems or low levels of red blood cells – anaemia)

And any one or more of the following:

  • more than 60 out of 100 (60%) abnormal plasma cells in your bone marrow
  • a serum free light chain ratio of more than 100
  • more than 1 lesion (involving your bone or bone marrow) on an MRI scan

Relapsed myeloma

Myeloma can respond very well to treatment and go into remission. Remission means that there is no sign of active disease in your body. Or the abnormal proteins can remain at the same level (plateau). This is called stable disease.

But the myeloma nearly always comes back or the protein level rises again in time. It is then called relapsed myeloma or recurrent myeloma.

Treatment

The stage of your myeloma helps your doctor decide what treatment you need. Treatment also depends on:

  • your symptoms
  • the results of your blood and bone marrow tests
  • your general health and levels of fitness
  • your personal wishes

If you don't have any symptoms

You don't usually have any treatment. Your doctor will keep a close eye on your myeloma. This is called active monitoring. You start treatment if your myeloma gets worse or you develop symptoms.

If you have symptoms

You are likely to have a combination of:

  • chemotherapy
  • biological therapy
  • steroids

If you're under 70 and are fit enough, your doctor might suggest further intensive treatment with high dose chemotherapy and stem cell transfusion (a stem cell transplant).

Once your myeloma is under control (in remission), you might have a course of biological therapy such as lenalidomide or thalidomide. This is to try to keep it under control for longer and is called maintenance therapy. 

Controlling symptoms

To treat symptoms you might have:

  • radiotherapy
  • surgery to make your bone stronger
  • bisphosphonate treatment - these drugs can reduce pain, lower levels of calcium in your blood and lower the risk of fractures of the spine
  • plasmapheresis to remove protein from your blood - this can help if high levels of protein are making your blood too thick and causing symptoms such as headaches
  • a blood transfusion, to help with symptoms of anaemia

If your myeloma comes back (relapses)

Your treatment depends on your individual situation, such as how long you were in remission for, what treatment you had and your current level of health and fitness.

If your myeloma was in remission for longer than 18 months after initial treatment, you might have the same combination of drugs again.

If it comes back sooner than that, your doctor may suggest a different type of treatment.

You might have treatment with:

  • the biological therapy bortezomib (Velcade)
  • a combination of chemotherapy drugs with or without a biological therapy, such as thalidomide or lenaliodmide
  • the steroid drug dexamethasone
Last reviewed: 
19 Dec 2015
  • International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma
    SV Rajkumar and others
    Lancet Oncolgy, 2014, Volume15, Issue 12, Pages 538-48

  • Cancer: Principles and Practice of Oncology (10th edition)
    VT De Vita, TS Lawrence and SA Rosenberg
    Lippincott, Williams and Wilkins, 2015

  • Multiple myeloma
    C Röllig and others 
    Lancet,2015, Volume 385, Issue 9983, Pages 2197-208

  • Cancer Staging Manual (7th edition)
    American Joint Committee on Cancer (AJCC), 2009

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