Rethinking Multiple Myeloma Treatment: The Biological and Clinical Insights Guiding Immune-Based Combinations

The standard of care for multiple myeloma has rapidly evolved to include immune-based therapies. However, achieving durable immune control and long-term survival, particularly in high-risk patients, remains difficult. In this article, we review the immune effects of existing and emerging therapies, dissect key drivers of resistance, highlight rational combinations and treatment-sequencing strategies, and summarize ongoing clinical trials that aim to optimize durable immune control. We discuss how the application of these biological and clinical insights may help us rethink multiple myeloma treatment to fully eradicate residual disease and elicit sustained natural and/or synthetic tumor-specific immunity. SIGNIFICANCE: Preclinical and clinical insights are reshaping how immune-based therapies are used in multiple myeloma. This review explores how optimizing the integration of natural and synthetic immunity can support a shift from disease control to deep, durable immune eradication, paving the way for personalized immune strategies tailored to individual immune profiles.