Myeloma

Myeloma is often called multiple myeloma because most people (90 per cent) have multiple bone lesions at the time it is diagnosed.

Myeloma is not a common disease. About 1,750 people in Australia are diagnosed with the disease each year. It accounts for 15 per cent of blood cancers and one per cent of all cancers generally. The disease is more often found in people over 60, which is partly explained by the ageing population. It is rare in people under 40. Myeloma is slightly more common in men than in women.

The symptoms of myeloma can include:

• bone pain or a broken bone without an obvious injury;
• frequent infections or an infection that is difficult to overcome;
• tiredness, shortness of breath or a racing heart;
• kidney problems;
• heavy nosebleeds or easy bruising;
• feeling sick, drowsy or confused; and
• abnormal blood counts.

The causes of myeloma are not known. We know that plasma cells become cancerous when there are certain changes in their DNA. DNA is found in all cells. It carries instructions that control how cells work. However, we do not yet know what causes DNA to change.

Risk factors for myeloma include:

• exposure to certain chemicals (dioxins used in industry);
• high levels of radiation; and
• the human immunodeficiency virus (HIV).

These factors have been linked to an increased risk, but they have not been proven to cause it.

People with monoclonal gammopathy of undetermined significance (MGUS) are more likely to develop myeloma.

Your doctor will examine you and refer you for tests to make a diagnosis. The test results will help them recommend a treatment plan for you.

Blood tests

Your doctor will take a blood sample to see how well your blood and kidneys are working, and to check your general health.
The main test blood test used is called serum protein electrophoresis. This measures the level of paraprotein in you blood, a protein produced by myeloma cells.

Another blood test called the serum free light chain assay may be used to check for a form of paraprotein known as free light chains.

Urine test

A urine test may be used to check for the Bence Jones protein, which is the light chain part of paraprotein and does not show up in blood tests. About one-third of people with myeloma make enough Bence Jones protein for it to be measurable in the urine.

Bone marrow biopsy

Blood cells develop in your bone marrow, so your doctor will want to check a sample of your bone marrow for signs of myeloma. A sample from your bone marrow is taken with a needle to remove a small amount of fluid (aspirate) or a small amount of bone and marrow (biopsy). You will be given a local anaesthetic to numb the area, pain relief or light sedation to help you feel relaxed.

Imaging tests

You will usually have at least one of the following to check if the myeloma has spread.

• chest x-ray;
• CT (computerised tomography) scan;
• PET (positron emission tomography)-CT scan; or
• MRI (magnetic resonance imaging).

Cytogenetic tests

Using the bone marrow biopsy, cytogenetic tests look for changes in the chromosomes within the myeloma cells, which are different to the normal cells in the body. This can help determine treatment options.

Staging

The tests conducted to diagnose myeloma help your specialist work out how far the cancer has progressed. This is known as staging, and it helps your health care team recommend the best treatment for you.

The R-ISS divides myeloma into stages I, II and III based on the results of various blood tests that check:

• levels of beta-2 microglobulin (ß2M)—a protein produced by myeloma cells that indicates the extent of disease.
• levels of albumin—a protein produced by the liver that indicates overall health.
• levels of lactate dehydrogenase (LDH)—an enzyme released into the blood when cells are damaged or destroyed.
• genetic information—the presence of one or more specific chromosomal abnormalities may identify people at highest risk of the disease progressing[DR1] .

Prognosis

Prognosis means the expected outcome of a disease. You may wish to discuss your prognosis with your doctor, but it is not possible for any doctor to predict the exact course of the disease. Instead, your doctor can give you an idea about the general prognosis for people with the same type and stage of cancer.

To come up with a prognosis, your doctor will consider:

• test results;
• the type of myeloma you have;
• the rate and extent of tumour growth; and
• other factors such as age, fitness and medical history.

These details will also help your doctor advise you on the best treatment options.

Treatment for myeloma can help control the disease, manage the symptoms and improve quality of life, but cannot cure it.

If the myeloma is under control (also called a plateau phase), people usually return to a state of good health. The good health may last for months or a few years.

For some people, the disease can be controlled for much longer periods. If the disease becomes active again (relapses), further treatment will be needed.

The treatment you receive for myeloma is dependent on a number of factors such as:

• The stage of your myeloma
• Your overall health
• How old you are
• Any treatment you have had previously.

For people undergoing treatment who have symptoms, the treatment will be targeted at minimising the amount of myeloma with the aim of achieving remission for as long as possible, or to stabilise the myeloma and stop its progression.

Common treatments used to treat myeloma include:

• Chemotherapy – the use of drugs to kill or slow the growth of cancer cells.
• cortico-steroids – hormones used in the treatment of disease.
• Interferon – substances produced by the body that can help the immune system fight cancer. Interferon can slow the growth of cancer cells or make them act like normal cells.
• blood stem cell transplantation – replaces stem cells that have been destroyed by high doses of chemotherapy and/or radiotherapy. The stem cells help the bone marrow recover and continue to produce healthy blood cells.
• targeted therapies – drugs that attack specific proteins on the surface of cancer cells to stop the cancer growing and spreading.
• immunotherapies – the use of specific drugs to stimulate the ability of the body’s own immune system to fight disease.
• radiation therapy – uses a controlled dose of radiation, such as focused x-ray beams, to kill or damage cancer cells
• bisphosphonates – drugs that help make weak bones stronger and less likely to break.
• clinical trial drugs not available for general use – drugs that are used as part of a research study to find better ways to prevent or treat disease.

Depending on how effective your treatment is, and the side effects you experience, you may require more than one type of treatment over time.

Most symptoms and side effects are caused by the build up of myeloma cells in the bone marrow and the presence of paraprotein in the blood or urine.

Bone disease

Bone disease is one of the most common complications experienced by people with myeloma. The myeloma cells release chemicals that damage the cells that normally repair damaged bone. When this happens, the bone breaks down faster than it can be repaired, causing bone pain, bone lesions or even fractures. The rapid breakdown of bone can lead to an increase in blood calcium levels (hypercalcaemia).

A group of drugs called bisphosphonates are used to treat bone disease. They help to control hypercalcaemia, manage existing bone disease and slow down any further bone destruction.

Pain

Pain is the most common symptom at diagnosis, often related to bone damage that has been caused by the disease. Regular reviews by pain management specialists will help keep your pain under control.

Kidney damage

Kidney problems can develop in people with myeloma for various reasons, including the paraprotein produced by myeloma cells, dehydration, infection, hypercalcaemia, as can some of the drugs used to treat myeloma and its symptoms.

The treatment for kidney damage in people with myeloma will depend on the cause. In many cases, the damage is temporary and the kidneys can recover.

High calcium levels in the blood

When bone cells break down, calcium is released into the blood. This condition is called hypercalcaemia. It can cause symptoms such as tiredness, nausea, constipation, bone pain, thirst, irritability and confusion.

People with hypercalcaemia need to drink extra fluids. However, they might also require treatment in hospital, which may include intravenous fluids, steroids and bisphosphonates. Treatment of the myeloma itself will often help to control the high calcium levels in the blood.

Fatigue

The level of your red blood cells may drop (anaemia), causing you to feel tired and breathless. This can be treated with blood transfusions. However, some people feel fatigued for weeks or months after cancer treatment, even once their blood count returns to normal.

Nerve and muscle effects

Some chemotherapy drugs can cause tingling (“pins and needles”), pain or loss of feeling in your fingers and/or toes, and muscle weakness in your legs. This is called peripheral neuropathy and it is usually a short-term issue, but for some people, it can last a long time or even be permanent.

Life with a myeloma diagnosis can present many challenges. It is important to take some time to adjust to the physical and emotional changes and establish a daily routine that suits you and the symptoms you’re living with. Your family and friends may also need time to adjust.

Because of the nature of myeloma, treatment may be ongoing, and it may be hard to accept that life won’t return to normal. For others, you may have mixed feelings when treatment ends, and worry that every ache and pain mean the cancer is active.

Cancer Council 13 11 20 can help you connect with other people with a similar diagnosis and provide you with information about managing the emotional and practical impacts.