Multiple myeloma begins in the bone marrow but as a disease it is “smart”; even when taken out of the bone marrow, it will find a way to grow elsewhere. So explained Dr Siobhan Glavey, a senior registrar in haematology at St James’s Hospital, who delivered an overview of multiple myeloma at the recent Patient and Family Awareness Day. She acknowledged its status as a complex disease and one of the lesser-understood malignancies. “It is something of a vague concept for a lot of people – when they are dealing with a tumour in a certain organ such as the breast or the bowel, it’s more of a solid concept in their mind as to what it is, has it spread, has it gone now.”
An extensive whole body assessment is needed in order to definitively diagnose the disease – this includes blood and urine tests to check for abnormal antibodies, or paraproteins, bone marrow tests such as aspirates and biopsies, and imaging such as MRI and/or PET scanning. Cytogenetic testing is
also carried out, and Dr Glavey explained that this is a test that looks at the genetics of the myeloma cells themselves, and not the patient’s genetics. This may indicate more about the “biological signature” of the disease and gives a clear picture of how the disease is affecting a patient. “This could be the most important tool we have in multiple myeloma to predict outcomes.”
CRAB is the acronym for the most common symptoms of multiple myeloma – elevated Calcium, Renal failure, Anaemia, or Bone problems. Dr Glavey added that cytogenetics is critical – this
assesses the genetics of the myeloma cells themselves, and may indicate more about the biological signature of the disease. “This has proved to be the most important tool to predict outcomes in multiple myeloma,” she said.
The principles of therapy in multiple myeloma are to stop the production of abnormal plasma cells, strengthen the bone and prevent fractures, treat anaemia and reduce fatigue, as well as promotion of wellbeing and quality of life. The balance between the treatment offered and the patient’s quality of life must be found, said Dr Glavey; “there is no point in giving a patient the strongest drug we have if it makes them feel dreadful and severely impacts their quality of life.” Hence individualised treatment in multiple myeloma has become a priority in recent years, and the influx of new drugs has made this increasingly possible, she added.
The ASCT remains the most effective therapy in eligible patients, providing the best chance of “deep and durable remission”, Dr Glavey continued. However this is not suitable for all patients, as there are significant associated side effects such as risk of infection and psychological distress so it is only offered on the basis of individual assessment, she explained.
Dr Glavey emphasised the importance of supportive care in multiple myeloma, calling it the “backbone” of treatment. Supportive care includes pain management, treatment of anaemia,
management of infections, as well as dealing with psychological distress, depression and anxiety that a person with multiple myeloma can face. It also relates to the management of any side effects associated with treatment, such as neuropathy, nausea/vomiting, low blood counts, skin rashes, and/or fatigue. “This allows patients to be cared for in a completely holistic way. It is essential to ensure the maximal benefit from treatment and quality of life,” she told the audience.
Preventive care is also critical, such as prevention of infections via vaccines and prophylactic antibiotics, the prevention of bone problems using calcium and vitamin D as well as bisphosphonates, and the prevention of kidney problems by staying adequately hydrated. Dr Glavey highlighted the importance of bone protection, explaining it is now known that myeloma weakens bones at the microscopic level even when fractures are not present. “This can cause areas of weakness in the bone and lead to fractures even where no trauma has occurred,” she explained, adding that if this occurs in spinal bones it can cause nerve compression and potentially serious neurological problems.
Multiple myeloma is a disease with widespread effects in the body – each patient is different and treatment needs to be tailored to the individual, concluded Dr Glavey. “Patient are living longer and better with multiple myeloma in 2017 than ever before, and that points not only to the better
treatments, but the better supportive care available now. We have made lots of progress but there is much more to do.”