Multiple myeloma (MM), a malignant plasma cell disorder, is the second most common haematological malignancy, accounting for approximately 14 per cent of all blood cancers worldwide. The highest incidence rates are observed in North America, Australia and New Zealand, exceeding four cases per one lakh population. Driven largely by population growth and ageing, the global burden of MM is projected to rise sharply; by 2045, annual new diagnoses are expected to increase by more than 71 per cent, reaching more than three lakh cases per year.
In Asia, the trajectory is even steeper than the global average, with incidence predicted to nearly double by 2050, reflecting demographic shifts and improved detection. However, mortality reduction in low- and middle-income countries (LMICs) remains slower than in western countries, underscoring persistent disparities in access to advanced therapies and comprehensive supportive care.
Over the past two decades, the introduction of novel agent-based induction regimens, widespread use of autologous stem cell transplantation, incorporation of maintenance therapy, and deeper insights into disease biology have significantly improved survival outcomes for newly diagnosed multiple myeloma.
The proportion of patients undergoing transplant varies widely: 40-50 per cent in the US (higher in large academic centres and lower in community settings), 35-45 per cent in Europe, and 20-30 per cent in Asia, with higher rates in countries such as Singapore and South Korea. In India, however, fewer than 30 per cent of eligible patients undergo transplantation at academic centres, with overall rates likely even lower.
Several factors contribute to this gap. The number of transplant centres (approximately 167) remains inadequate for a population of 1.4 billion. Most centres are located in major cities, requiring patients to travel long distances and stay for four to six weeks. Additional barriers include a shortage of trained personnel (transplant physicians, nurses, and technical staff), limited transfusion services, financial constraints, and patient reluctance.
A study in AIIMS found that logistical challenges were a major cause of delay, with patients needing to arrange accommodation or manage family commitments such as children’s exams or marriages. Financial constraints were also frequently cited.
The time from diagnosis to transplant varies across regions: four to six months in the US, five to seven months in Europe, and six to nine months in much of Asia. In India, however, the interval is often nine to 12 months, with some patients experiencing extreme delays. These prolonged timelines reflect not only financial and logistical barriers but also disparities in access to diagnostics, supportive care, and transplant facilities. Out-of-pocket expenditure further compounds inequity.
Post-transplant maintenance therapy is now standard worldwide, most commonly with lenalidomide for two to three years. Thalidomide, used historically, has largely been replaced, though low-dose thalidomide (50 mg/day) or bortezomib may still be used in select centres in LMICs. Adverse effects of lenalidomide can also affect dose intensity and adherence, particularly in settings where patients must travel long distances for care.
Emerging strategies include the addition of daratumumab to lenalidomide maintenance in patients with measurable residual disease (MRD) post-transplant, an approach currently under investigation.
The availability of generic and biosimilar drugs (including agents for induction, high-dose melphalan for conditioning, and supportive therapies such as G-CSF and plerixafor) has significantly reduced the cost of myeloma transplantation in LMICs. The use of non-cryopreserved stem cells, which eliminates the need for expensive cryopreservation infrastructure, provides further cost savings. Lower costs of hospitalisation, physician services, and nursing care also contribute to making transplantation more affordable, with outcomes comparable to international standards.
The past decade has seen major advances in the management of relapsed/refractory (RR) myeloma, including anti-CD38 monoclonal antibodies such as daratumumab and isatuximab, bispecific T-cell engagers (eg, teclistamab and talquetamab), and CAR T-cell therapies. These innovations have led to unprecedented depth of response in heavily pretreated patients.
In resource-limited settings, however, access to these therapies remains a challenge. Outcomes, therefore, depend on timely triaging, judicious use of available agents, and participation in clinical trials. Such pragmatic approaches can deliver meaningful improvements in survival and quality of life, even before newer immunotherapies become widely accessible.
Dr Kumar is a professor at the department of medical oncology, AIIMS, Delhi.
