The first 60 days: Relapsed or refractory multiple myeloma

Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.

These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.

• Medical oncologistNamed in the standard of care for: First relapse, lenalidomide-refractory, Triple-class exposed, two or more prior lines, After BCMA-directed therapy, Toxicity management.
• Transplant and cell therapy teamNamed in the standard of care for: First relapse, lenalidomide-refractory, Triple-class exposed, two or more prior lines.
• Palliative and supportive care teamNamed in the standard of care for: First relapse, lenalidomide-refractory.

A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.

Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.

1. 1.Triple-class exposed, two or more prior linesNCCN Guidelines: Multiple Myeloma

   BCMA CAR-T (cilta-cel or ide-cel, KarMMa-3) where slots and fitness allow; BCMA bispecific (teclistamab, elranatamab, linvoseltamab) otherwise; teclistamab-daratumumab (MajesTEC-3).

   Ciltacabtagene autoleucelIdecabtagene vicleucelKarMMa-3CARTITUDE-1TeclistamabElranatamabLinvoseltamabMajesTEC-1MajesTEC-3LINKER-MM1MagnetisMM-3
2. 2.After BCMA-directed therapyNCCN Guidelines: Multiple Myeloma

   Talquetamab against GPRC5D (MonumenTAL-1); selinexor combinations; CELMoDs and trispecifics in trials.

   TalquetamabMonumenTAL-1SelinexorIberdomideMezigdomideBCMA-directed therapy → GPRC5D-directed therapy
3. 3.Toxicity management

   Step-up dosing and tocilizumab for cytokine release syndrome, immunoglobulin replacement and antimicrobial prophylaxis on bispecifics, neurological monitoring after cilta-cel, ocular examinations on belantamab.

   Step-up dosing (T-cell engagers)Cytokine release syndrome (CRS)ICANS (neurotoxicity)Caution: T-cell redirectors and infections
4. 4.First relapse, lenalidomide-refractoryNCCN Guidelines: Multiple Myeloma

   Daratumumab or isatuximab with carfilzomib or pomalidomide and dexamethasone; belantamab mafodotin with bortezomib- or pomalidomide-dexamethasone (DREAMM-7, DREAMM-8); cilta-cel after one to three lines (CARTITUDE-4).

   DaratumumabIsatuximabCarfilzomibPomalidomideDexamethasoneBelantamab mafodotinDREAMM-7DREAMM-8Ciltacabtagene autoleucelCARTITUDE-4

Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.

Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.

• A Clinical Study Comparing SG301 Plus Pomalidomide and Dexamethasone to Placebo Plus Pomalidomide and Dexamethasone in Relapsed or Refractory Multiple Myeloma PatientsPhase 3 · recruiting · NCT06508983A Phase 3 Randomized, Placebo-controlled, Double-blind, Multicenter Study Comparing SG301 in Combination With Pomalidomide and Dexamethasone Versus Placebo in Combination With Pomalidomide and Dexamethasone in Patients With Relapsed or Refractory Multiple Myeloma
• A Multicenter, Randomized, Open-label, Parallel-group, Controlled, Superiority Phase III Clinical Study Comparing the Efficacy and Safety of F182112 Versus Standard of Care in Patients With Relapsed or Refractory Multiple MyelomaPhase 3 · recruiting · NCT07579234Phase III Clinical Study of F182112 in Patients With Relapsed or Refractory Multiple Myeloma
• A Phase III Study of Eque-cel in Subjects With Len-refractory RRMM (FUMANBA-03)Phase 3 · recruiting · NCT06464991A Phase III Randomized, Controlled Study of Equecabtagene Autoleucel Injection in Subjects With Lenalidomide-Refractory R/R Multiple Myeloma
• A Study Comparing Anitocabtagene Autoleucel to Standard of Care Therapy in Participants With Relapsed/ Refractory Multiple MyelomaPhase 3 · active · NCT06413498A Phase 3, Randomized, Open-Label Study to Compare the Efficacy and Safety of Anitocabtagene Autoleucel Versus Standard of Care Therapy in Participants With Relapsed/Refractory Multiple Myeloma
• A Study Comparing AZD0120, a Dual-targeted CAR-T Against B-cell Maturation Antigen (BCMA) and CD19, Versus Standard Regimens in Participants With RelaPhase 3 · recruiting · NCT07391657A Phase III Open-label, Randomised, Multicentre Study Comparing AZD0120, a Dual-Targeting Autologous Chimeric Antigen Receptor T-cell (CART) Therapy Directed Against BCMA and CD19, Versus Standard Regimens in Participants With Relapsed Refractory Multiple Myeloma.

Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.

• Free in oncologyFree testing, helplines, rides and lodging, second opinions and trial travel help, with who is eligible.
• Financial helpManufacturer programmes, national schemes and charities by country and product.
• Second opinionExpert centres for this cancer in your country and how referral works.

• Relapsed or refractory multiple myeloma: the full pageMyeloma almost always returns, and each return is harder to treat. Two kinds of immune therapy aimed at the BCMA protein on myeloma cells, CAR-T cells (KarMMa-3, CARTITUDE-4) and off-the-shelf bispecific antibodies (MajesTEC), now give deep remissions after other drugs fail, and a second target, GPRC5D, gives another option.
• One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
• Treatment sequencingWhich treatment tends to follow which, line by line.
• NavigatorStandard of care for your stage, what you have tried, and trials near you.