Multiple myeloma in Black patients: twice the risk

Multiple myeloma is a cancer of plasma cells, the bone-marrow cells that normally make antibodies. In myeloma, abnormal plasma cells multiply, crowd out healthy blood cells, weaken bone, and flood the blood and urine with one useless antibody protein (called an M protein). That protein, and the marrow takeover, drive the symptoms.

Almost every case of myeloma is preceded by a silent stage called MGUS, monoclonal gammopathy of undetermined significance. MGUS means the M protein is present but there is no organ damage and no cancer yet. Most people with MGUS never progress. It is usually found by accident on bloodwork done for something else, and it carries a small, steady yearly risk of turning into myeloma, which is why it is monitored rather than treated.

MGUS is more common in Black adults. In a national study of more than 12,000 people published in Leukemia in 2014, the adjusted prevalence of MGUS was 3.7% in Black adults compared with 2.3% in White adults. The researchers concluded that the higher myeloma rate in Black Americans is explained in large part by this higher MGUS prevalence, and that MGUS in Black patients more often carried features linked to higher progression risk. The practical takeaway: if you are Black and MGUS shows up on a lab report, it is worth a referral to track it.

Myeloma is the most common blood cancer in Black Americans, and the American Cancer Society reports it is more than twice as common in Black people as in White people. Black patients also tend to be diagnosed younger. That younger age matters: it shifts when the disease should be on a clinician's radar, well before the textbook profile of a patient in their late 60s or 70s.

Despite the higher risk, myeloma is still uncommon overall, accounting for about 1.7% of all new cancers in the United States. That rarity is part of the problem. A primary-care clinician may see only a handful of cases in a career, so the vague early symptoms get attributed to more common explanations first.

Myeloma rarely announces itself. The damage it does is summarized by doctors with the acronym CRAB, and each letter is a reason people get sent home with the wrong explanation.

• C, high Calcium. Bone breakdown releases calcium into the blood. It causes thirst, frequent urination, constipation, confusion, and fatigue, symptoms easy to chalk up to dehydration or stress.
• R, Renal (kidney) problems. The M protein can damage the kidneys. It shows up as rising creatinine on a blood test, often with no symptoms the patient can feel.
• A, Anemia. Marrow crowded with cancer cells makes fewer red blood cells. The result is fatigue, weakness, and breathlessness, frequently blamed on age or a busy life.
• B, Bone pain or fractures. Myeloma eats away at bone, most often in the spine, ribs, hips, and skull. It presents as persistent back or rib pain, or a bone that breaks from a minor fall or even spontaneously.

Two more signs round out the picture: ongoing fatigue and frequent or hard-to-shake infections, because the abnormal plasma cells crowd out the normal antibody-making ones. Anemia and bone pain are the two that most often bring people in, and both are the kind of complaint that gets a quick reassurance rather than a workup.

If you are tracking unexplained anemia on your own labs, our guide to iron-deficiency anemia in Black women covers when low blood counts deserve a deeper look rather than a routine iron prescription.

Two forces stack up. The first is that myeloma's symptoms mimic ordinary problems. Back pain reads as a strain or arthritis. Fatigue reads as aging or overwork. A high calcium or a rising kidney number on a panel can be filed away as a fluke and not connected to the back pain in the same chart.

The second is bias and access. Black patients are more likely to have pain underestimated and concerns discounted, and they wait longer to start modern treatment after diagnosis. The delay compounds: a later diagnosis often means more bone damage and more kidney injury already done. The fix is not complicated. It is naming the pattern out loud and asking for the protein tests rather than waiting for a third or fourth visit.

The workup is straightforward and starts with cheap tests:

• Blood and urine protein tests. Serum protein electrophoresis (SPEP) and a urine version look for the abnormal M protein. This is the front door.
• Serum free light chains. A blood test that catches forms of myeloma the standard protein test can miss, and useful for tracking risk.
• Routine bloodwork. A complete blood count (for anemia), calcium, creatinine (kidney function), and total protein often hold the first clues.
• Imaging. Whole-body low-dose CT, MRI, or PET-CT looks for the bone lesions myeloma causes. Plain X-rays miss early damage.
• Bone marrow biopsy. The definitive test. A sample of marrow confirms the diagnosis and is sent for cytogenetic (chromosome) testing that guides treatment and risk.

Ask that any bone marrow sample go for cytogenetic and FISH testing. Those results sort myeloma into risk groups and shape which drugs you should get. Skipping them means flying blind on treatment choice.

Myeloma is not curable for most people, but it has become one of the clearest success stories in cancer treatment. Five-year relative survival reached 63.7% for people diagnosed between 2016 and 2022, up from roughly a quarter half a century ago. The gains came from proteasome inhibitors, immunomodulatory drugs, monoclonal antibodies, stem-cell transplant, and now CAR-T cell therapy and bispecific antibodies.

The catch is that Black patients are less likely to receive the treatments that produced those gains. In a study of more than 3,000 patients published in Cancer in 2017, after adjusting for overall health and access barriers, Black patients were 37% less likely to undergo stem-cell transplant and 21% less likely to receive the drug bortezomib. Underuse of those treatments was tied to a 12% higher risk of death. The same gaps show up for CAR-T, the newest and most expensive option.

The trials that decide which drugs reach the market have largely left Black patients out. An analysis of myeloma drug-approval trials submitted to the FDA, published in Blood Advances in 2022, found Black patients were only 4% of participants, even though they bear a far larger share of the disease. Part of the reason, the American Society of Hematology has noted, is that trial eligibility rules (around kidney function and prior conditions) disproportionately screen out minority patients.

Here is the part worth holding onto: the disparity is not biology. In a Veterans Affairs study of more than 15,000 patients published in Blood in 2019, where access to therapy was equal, Black patients had survival that was as good as or better than White patients. Equal access closes the gap. That makes pushing for a myeloma specialist, full genetic testing, and a clinical-trial conversation not optional extras but the difference-maker.

Kidney damage is one of the most common ways myeloma first surfaces and one of the things that can exclude patients from trials, so unexplained kidney trouble deserves its own workup. Our explainer on cancer screening for Black adults covers a related lesson: catching disease earlier, before symptoms pile up, is what changes survival.

If you have unexplained bone pain, anemia, kidney trouble, or high calcium, ask your clinician directly for SPEP, free light chains, and a urine protein test, and ask them to look at those results together rather than one at a time. If anything comes back abnormal, ask for a referral to a hematologist or oncologist who treats myeloma, request cytogenetic testing on any bone marrow sample, and ask whether a clinical trial is open to you. A myeloma specialist, not just a general oncologist, is associated with better outcomes.

Find a Black oncologist or hematologist in our directory to start that conversation with someone who will take your history seriously.