The progression to multiple myeloma (MM) in patients with monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM) needs to be understood in order to prevent and manage the condition to the best of our ability. Topical themes covered by the experts in this panel discussion include whether we are ready to treat SMM outside of trials, new mouse models of progression, the role of the immune system in this disease transition, and epigenetic modifications in MM. At the Myeloma 2018 meeting in San Diego, CA, Larry Boise, PhD, of Emory University School of Medicine, Atlanta, GA, chairs a discussion with Elisabet Manasanch, MD, from the MD Anderson Cancer Center, Houston, TX, and Suzanne Lentzsch, MD, PhD, from Columbia University Medical Center, New York, NY.