Virtually all patients with MM will relapse after responding to initial treatment. Access to the best available therapies, including clinical trials and treatment with a multidisciplinary team, are crucial to achieving the best outcomes for relapsed disease.

Signs and symptoms will depend on if there is end-organ damage as a result of clinical relapse. Patients may be asymptomatic when there is progressive disease without end-organ damage.

Indicators of progression or relapse may include:

• new or increased size of plasmacytomas or bone lesions
• new or worsening end-organ damage (e.g. anaemia, hypercalcaemia, renal impairment)
• progressive rise in paraprotein, serum free light chain or urinary Bence Jones

For specific criteria of clinical relapse and progressive disease, see the MSAG Clinical practice guideline: multiple myeloma (Quach & Prince 2019).

Managing relapsed or progressive MM is complex and should therefore involve all the appropriate specialties in a multidisciplinary team including palliative care where appropriate. From the time of diagnosis, the team should offer patients appropriate psychosocial care, supportive care, advance care planning and symptom-related interventions as part of their routine care. The approach should be personalised to meet the patient’s individual needs, values and preferences. The full complement of supportive care measures as described throughout the optimal care pathway and in Appendices A, B and C should be offered to assist patients and their families and carers to cope. These measures should be updated as the patient’s circumstances change.

Survivorship care should be considered and offered at an early stage. Many people live with MM for many years. As survival is improving in many patients, survivorship issues should be considered as part of routine care. Health professionals should therefore be ready to change and adapt treatment strategies according to disease status, prior treatment tolerance and toxicities and the patient’s quality of life, in addition to the patient’s priorities and life plans.

If there is an indication that a patient’s cancer has returned, care should be provided under the guidance of a treating specialist. Each patient should be evaluated to determine if referral to the original multidisciplinary team is necessary. Often referral back to the original multidisciplinary team will not be necessary unless there are obvious aspects of care involving different therapeutic and supportive care disciplines not otherwise accessible. The multidisciplinary team may include new members such as palliative care specialists.

There are many therapeutic regimens available to treat relapsed or progressive MM. The choice

of salvage regimen should take into account patient factors (age and frailty), disease factors (tempo of relapse, risk-group stratification), prior treatment-related factors (responsiveness and side effects to prior treatment type) and the patient’s preferences.

In managing people with relapsed or progressive MM, enrolment into a clinical trial is the first preference. If no clinical trial is available, treatment may include these options (Quach & Prince 2019):

• using a different drug regimen that contains drugs of a different class or a different drug of the same class
• retreatment with a previous regimen for those who achieved treatment-free remission of at least one year without significant toxicity, but response length and quality will likely not be as good as before
• salvage ASCT in fit patients who achieved a durable response after the first ASCT and who have enough stem cells in storage
• conventional doses of cyclophosphamide, non-myeloablative doses of melphalan, low-modest doses of corticosteroids or palliation (after all newer agents and different treatment combinations have been exhausted).

Refer to the updated MSAG clinical guideline for managing relapsed MM (Quach & Prince 2019).

The potential goals of treatment should be discussed, respecting the patient’s cultural values. Wherever possible, written information should be provided.

Advance care planning is important for all patients with a cancer diagnosis but especially those with advanced disease. Where appropriate, patients, their family or carer should be encouraged to think and talk about their healthcare values and preferences and consider developing an advance care directive to convey their preferences for future health care (Australian Government Department of Health 2021a).

These conversations should begin soon after the cancer diagnosis, and can be revisited intermittently throughout the disease course. Importantly, advance care planning is a process rather than single event.

More information

Refer to section 4.3 ‘More information’ for links to resources.

Refer patients and carers to Advance Care Planning Australia  or to the Advance Care Planning National Phone Advisory Service on 1300 208 582.

Early referral to palliative care can improve the quality of life for people with cancer and in some cases may be associated with survival benefits (Haines 2011; Temel et al. 2010; Zimmermann et al. 2014). The treatment team should emphasise the value of palliative care in improving symptom management and quality of life to patients and their carers. Refer to section 4.3 for more detailed information.

The lead clinician should ensure timely and appropriate referral to palliative care services. Referral to palliative care services should be based on the patient’s need and potential for benefit, not prognosis.

More information

Refer to the end of section 4.3 ‘Palliative care’ for links to resources.

The treatment team should support the patient to participate in research and clinical trials where available and appropriate.

For more information visit:

• Cancer Australia 
• Australian New Zealand Clinical Trials Registry
• Australasian Leukaemia and Lymphoma Group
• ClinTrial Refer 
• Clinical Trials for an international view.