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The stage of your myeloma tells your doctor about how it is affecting you and how it might develop. Doctors use the stage of your myeloma to help them decide on the best treatment for you. 

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 measure the amount of these substances in the blood:

  • are ß2-microglobulin
  • albumin
  • lactate dehydrogenase (LDH)

You will also have blood tests to look for particular gene changes (mutations). You might hear this call cytogenetic tests. Doctors describe the results as low or high risk cytogenetics. 

 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)
  • normal LDH level
  • low risk cytogenetics

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 
  • normal LDH
  • low risk cytogenetics

Stage 3 means:

  • the level of ß2-M is more than 5.5 mg/L 
  • high LDH level
  • high risk cytogenetics

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 describe your myeloma as either:

  • symptomatic (with symptoms)
  • asymptomatic (without symptoms)

Myeloma without symptoms (asymptomatic myeloma)

Asymptomatic myeloma is also called smouldering or indolent myeloma. This means you don't have symptoms or any tissue or organ damage. 

But you have one or both of these:

  • paraprotein in your blood that is more than 30 g/L
  • level of abnormal plasma cells in your bone marrow that is between 10% and 60%

You don't 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 does progress to symptomatic myeloma, but your doctor won't be able to say when this will happen. The risk of myeloma progressing is highest in the first 5 years after diagnosis. 

About 5 out of 10 people (50%) with asymptomatic myeloma develop symptoms and need treatment within the first 5 years. 

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


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

You are likely to have a combination of:

  • chemotherapy
  • targeted drugs
  • steroids

If you are fit enough, your doctor might suggest intensive treatment with high dose chemotherapy and stem cell transplant.

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

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


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 targeted drug bortezomib (Velcade)
  • a combination of chemotherapy drugs with or without a targeted drug, such as thalidomide or lenaliodmide
  • steroids

Treatment to control symptoms

You might have one or more of these treatments:

  • radiotherapy
  • surgery to lower the risk of bone fractures
  • bisphosphonates to lower calcium levels, reduce pain and lower the risk of spinal fractures
  • plasma exchange (plasmapheresis) to lower protein levels in the blood and reduce symptoms such as headaches
  • blood transfusions to treat tiredness (caused by low red blood cell levels)
Last reviewed: 
24 Oct 2018
  • 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 (8th edition)
    American Joint Committee on Cancer (AJCC), 2017

  • Multiple myeloma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up
    P. Moreau and others
    Annals of Oncology 28 (Supplement 4): iv52–iv61, 2017

Information and help