Treatment for multiple myeloma is changing quickly — and that is good news for patients.
In 2019, the American Society of Clinical Oncology (ASCO) and Ontario Health jointly published evidence-based recommendations for the treatment of multiple myeloma.1 Since then, several major clinical trials have reshaped how this disease is managed.
In 2026, updated guidelines were published in the Journal of Clinical Oncology.2 The updated guidelines are based on a systematic review and were developed by a multidisciplinary expert panel, which included a patient representative and an ASCO guidelines staff member with health research methodology expertise.
Over the past six to seven years, the treatment landscape for multiple myeloma has evolved substantially. The introduction of novel therapies has improved outcomes across all risk categories but has also increased the complexity of treatment selection. The new guidelines synthesize results from more than 150 clinical trials into a practical framework to guide treatment decisions.
Stem cell transplant: Age is not the only factor
The update guidelines emphasize that transplant eligibility should be based on overall patient assessment rather than age alone.
For transplant-eligible patients, quadruplet therapy followed by autologous stem cell transplant remains the standard of care. Transplant planning should be initiated early in the course of treatment.
Post-transplant maintenance is generally recommended for at least two to three years.
Patients who are considered transplant-ineligible but have good functional status may also benefit from upfront quadruplet therapy.
Treatment for relapsed or refractory myeloma
For patients with relapsed or refractory myeloma, referral to a transplant or cellular therapy center for consideration of CAR T-cell therapy is strongly recommended.
CAR T is now considered a cornerstone of treatment in the relapsed/refractory setting due to high response rates and the potential for durable remissions. Importantly, every effort should be made to avoid using bispecific antibodies that target BCMA before BCMA-directed CAR T-cell therapy.
In patients whose disease has relapsed following CAR T therapy, or in those who are not eligible for CAR T, treatment options include:
- Bispecific antibodies
- Antibody–drug conjugates
- Targeted small-molecule therapies
Whenever possible, combinations of previously unused agents are preferred, and treatment strategies should be individualized to each patient.
A new focus: Smoldering myeloma
Smoldering myeloma is a new focus in the guidelines.
Patients with low- or intermediate-risk smoldering myeloma should not receive therapy and should instead be monitored carefully.
Patients with high-risk smoldering myeloma may be considered for careful observation versus treatment with daratumumab based on the AQUILA trial.3
Moving forward
The updated ASCO-Ontario Health guidelines reflect the rapid pace of progress in the treatment of multiple myeloma. While therapeutic advances have improved patient outcomes, they also require thoughtful, individualized decision-making guided by the latest evidence.
For additional information or to speak with a physician, please call 404-255-1930.
LEARN MORE ABOUT MULTIPLE MYELOMA TREATMENT AT NORTHSIDE.
References:
- Mikhael J, Ismaila N, Cheung MC, et al. Treatment of multiple myeloma: ASCO and Ontario Health (Cancer Care Ontario) clinical practice guideline. Journal of Clinical Oncology. 2019;37(14):1228–1263.
- Kicks LK, et al. Updated ASCO–Ontario Health guideline for treatment of multiple myeloma. Journal of Clinical Oncology. 2026:JCO2502587.
- Dimopoulos MA, et al. Daratumumab or observation for high-risk smoldering multiple myeloma. New England Journal of Medicine. 2025;392(18):1777–1788.
