Autologous stem cell transplantation is recommended as part of initial treatment of symptomatic multiple myeloma, however studies suggest the uptake of transplantation in the community is lower than expected. We analysed 225 registry-identified patients with myeloma using detailed clinical and demographic data and found that only 55% of patients proceeded to transplantation. Medical comorbidity, stage and physician type accounted for some cases not proceeding to transplantation, however neither age alone nor rural residence affected the rate of transplantation. Background: Guidelines for the management of symptomatic multiple myeloma (MM) recommend upfront autologous stem cell transplantation (ASCT) for transplant-eligible patients. Patients and Methods: Using population-based data, we examined the characteristics of transplant-eligible patients who do not undergo upfront ASCT. Altogether, 686 newly diagnosed MM cases were identified through the population-based central cancer registry in Victoria, Australia from 2008 to 2009. We performed a detailed review of clinical notes and follow-up for at least 12 months after diagnosis for a subset of 225 patients who were aged < 70 years at diagnosis and had symptomatic MM. Results: Of these 225 patients, 123 (55%) proceeded to receive upfront ASCT. Patient and disease factors associated with not receiving upfront ASCT were the presence of severe medical comorbidities, MM-associated renal impairment, and initial referral to a medical oncologist rather than a hematologist. Place of residence (rural vs. metropolitan) was not significant. Of 121 patients aged < 65 years at diagnosis who had minor or no comorbidities, only 75 (62%) proceeded to upfront ASCT. Conclusion: A substantial percentage of apparently transplant-eligible patients with newly diagnosed MM do not proceed to upfront ASCT. Community practice appears to diverge from clinical guidelines. The reasons for this divergence require further study but reasons may include perceptions of toxicity vs. benefits of upfront ASCT.