Multiple Myeloma Management in a Large Low- and Middle-Income Country: Lessons From India in Balancing Cost and Clinical Efficacy in Resource-Limited Settings

Management of multiple myeloma has transformed care of patients in high-income countries. Use of proteasome inhibitor-immunomodulator (IMiD) triplets and anti-CD38-based quadruplets and routine use of front-line autologous stem-cell transplantation (ASCT) as consolidation have extended survival beyond a decade for most newly diagnosed cases. However, in low- and middle-income countries (LMICs), care delivery is constrained by high out-of-pocket expenditure, limited transplant center infrastructure, erratic drug supply, and inequities in diagnostic access. This review aims to contextualize global advances within resource-limited settings in India and to provide a pragmatic, evidence-informed framework for optimizing outcomes where cost and capacity are major determinants of care. We integrate evidence from pivotal phase II/III international trials and real-world cohorts evidence from local studies and expert consensus to evaluate therapeutic choices across the disease continuum. Bortezomib, lenalidomide, and dexamethasone (VRd) remains the most cost-effective induction regimen, whereas CD38-based quadruplets offer incremental benefit but are often limited by affordability in LMIC settings. Early or frontline use of ASCT significantly deepens response and extends progression-free survival at a fraction of the cost of continuous use of monoclonal antibody therapy. At relapse, antibody-sparing triplets such as pomalidomide-bortezomib-dexamethasone or carfilzomib-dexamethasone are effective alternatives, whereas alkylator-based regimens and salvage ASCT remain valuable when novel agents are inaccessible. Emerging immunotherapies remain largely inaccessible in LMIC settings. The review emphasizes the need for the development of equitable access strategies, government procurement initiatives, and patient-assistance programs to translate global therapeutic advances into real-world benefits in resource-constrained settings. By systematically integrating clinical evidence with local economic considerations and health system realities, this review provides a roadmap for delivering high-value care in LMICs, balancing efficacy, affordability, and equity.