Multiple myeloma

Symptoms Of Multiple Myeloma

During the initial stages of multiple myeloma the symptoms may not be noticeable and may vary depending on the person. However, as the disease progresses most people experience some of the commonly observed symptoms. 

The common symptoms are generally referred to by the acronym CRAB which stands for:

C: Calcium (elevated levels)

R: Renal failure 

A: Anemia 

B: Bone damage 

Other commonly observed signs and symptoms of multiple myeloma include:

• Nausea
• Bone pain, especially in the spine or chest
• Constipation
• Mental fogginess or confusion
• Loss of appetite
• Tiredness
• Frequent infections
• Weakness or numbness in your legs
• Excessive thirst
• Problems with urination
• Vision loss or vision problems
• Weight loss

Causes Of Multiple Myeloma

In this type of cancer, abnormal plasma cells develop in the bone marrow and reproduce quickly. The rapid reproduction of cancerous myeloma cells overtakes the production of healthy cells in the bone marrow leading to the disease. 

The exact cause of multiple myeloma is not known. However, frequent alterations and mutations of genes, especially chromosome 14, are commonly found in multiple myeloma. In addition, other mutated genes like c-Myc, NRAS, KRAS, and BRAF may participate in plasma cell proliferation.

The cancerous plasma cells continue trying to produce antibodies, as healthy plasma cells do, but these cells produce abnormal antibodies (monoclonal proteins, or M proteins) that do not function as normal antibodies. These abnormal antibodies build up in the body and cause complications like kidney damage. Infiltration of cancer cells also increases the risk of bone disorders.

Risk Factors For Multiple Myeloma

The exact cause for multiple myeloma is hard to know however, researchers believe that certain factors do increase the risk of getting the disease.

Increasing age 

As one ages, the risk of getting multiple myeloma increases. Most people get diagnosed with the disease in their mid 60s. More than 75% of the cases were reported between the age group of 55-85 years. 

Gender 

Multiple myleoma is about 1.5 times more common among men than women, globally. Suggested underlying factors include discrepancies in health-risk behaviors such as smoking and alcohol consumption, and higher rates of obesity among men.

Ethnicity 

According to medical literature, the black race is more likely to develop multiple myeloma compared to the other races. 

Environmental factors

Exposure to chemicals such as benzene, insecticides, herbicides, hair dyes, organic solvents, and radiation have been found to increase the risk of developing multiple myeloma. 

Family history 

Inherited variations in certain genes could contribute to the development of multiple myeloma for some individuals. Therefore, close relatives of people with multiple myeloma may have an increased risk of developing the disease. 

Personal history of  monoclonal gammopathy of unknown or undetermined significance (MGUS)

MGUS is a benign proliferation of a plasma cell that results in production of monoclonal antibodies in high amounts (but not as high as seen with multiple myeloma). MGUS is a significant risk factor for the development of multiple myeloma. About 19% of MGUS patients develop multiple myeloma in about 2 to 19 years after diagnosis of MGUS.

Inflammatory diseases

Inflammatory diseases like type 2 diabetes, heart disease and rheumatoid arthritis can increase the risk of multiple myeloma. However, this relationship is not well established.

Other factors 

Other factors contributing to disease occurrence include obesity, tobacco and alcohol consumption although they are not well established as the risk factors for multiple myeloma.

Diagnosis Of Multiple Myeloma

A thorough clinical evaluation is required for the effective diagnosis of multiple myeloma. Based on the early signs and symptoms of the disease, your doctor will ask you to get a physical examination, followed by some laboratory tests, imaging tests and if needed, a biopsy as well. Here are the tests that will be a part of a comprehensive diagnosis of multiple myeloma.

Physical examination

When you experience the early signs and symptoms, book an appointment with your physician at the earliest. Your doctor may ask you questions and enquire about your medical history. Based on the answers, he may suggest some of the following clinical tests to confirm the presence of the disease:

A. Blood tests

1. Complete blood count (CBC) 

CBC measures several components of the blood, including red blood cells, white blood cells, platelets and others. The following levels are checked while studying the results of a CBC.

• A decreased level of hemoglobin (anemia)
• A decreased platelet count (thrombocytopenia) that can cause bleeding problems 
• A decreased level of white blood cells (granulocytopenia) which causes a weakened immune system.

Urea nitrogen is the waste product formed by the body after consumption of food. The liver breaks down the protein in the food and produces urea nitrogen which is released into the blood and eventually ends up in the kidneys. When the kidneys are healthy, they effectively remove the blood urea nitrogen; however unhealthy kidneys are unable to do so and leave more of it in the blood. Therefore, BUN test helps to see how much of the waste product remains in the blood and helps to detect the health of the kidneys. 

Laboratory based blood chemistry tests will help to check for the levels of blood creatinine, albumin, calcium, and other electrolytes.

3. Creatinine laboratory test
The creatinine test helps to measure how efficiently the kidneys are able to remove the waste from blood. Creatinine is a natural waste product which is present in the blood and urine. Kidneys remove creatinine from the body by filtering it from the blood and then releasing it into the urine. This test measures the amount of creatinine in the blood. 

High creatinine levels mean that the kidneys are not functioning well and are common in people with myeloma.

4. Albumin test

Albumin is a protein produced by the liver and its function is to carry nutrients and prevent body fluids from leaking into the body. A serum albumin test checks the amount of albumin in the body. Any abnormality in the level of albumin indicates a likelihood of liver disease, kidney disease or nutritional deficiency. Low levels can be seen in myeloma.

5. Calcium test

Calcium is a mineral found in the body responsible for many vital functions like maintaining bones strength, muscles, nerves function, and blood clotting. Abnormal levels of calcium can lead to several complications in the body like kidney disease, bone disease, and multiple organ tumors.

Calcium levels may be high in people with advanced myeloma and cause symptoms of fatigue, weakness, and confusion.

6. Lactate dehydrogenase test

Serum lactate dehydrogenase (LDH) test measures the levels of the enzyme lactate dehydrogenase in the blood. This enzyme is majorly involved in energy production and is found in nearly all of the body’s cells, with the highest levels in the cells of the heart, liver, muscles and kidneys. It is released in the bloodstream as a result of damage to the tissues following an injury.

A blood test to measure lactic dehydrogenase (LDH) levels can be a useful indicator of a patient’s prognosis as high levels can indicate cancer recurrence.

7. Quantitative immunoglobulins

This test helps to measure the levels of different immunoglobulins present in the blood such as IgA, IgD, IgE, IgG, and IgM. The quantitative analysis of these immunoglobulins helps to see if they are abnormal, suggesting the presence of disease or infection. In multiple myeloma, their levels usually differ from what their normal ranges usually are. 

B. Urine test

Urine tests can be used to:

•  Measure the amount of protein in the urine
•  Presence of free light chains
•  Test for creatinine, a waste product excreted by the kidneys
•  Presence of bilirubin, a breakdown product of hemoglobin

You might most likely be asked to give a sample of urine that has been collected over a 24-hour period, so it can measure how much myeloma protein is present. 

Urine protein electrophoresis (UPE or UPEP) and urine immunofixation may be done to look for free light chains in the urine and to assess kidney function. 

C. Bone marrow studies and biopsy

It is a medical procedure used as a diagnostic method in which a piece of the tissue or a sample of the cells is removed from the body and is tested in a laboratory. Multiple myeloma is characterized by an increased number of plasma cells in the bone marrow and therefore a bone marrow biopsy can help. It can be done at the doctor’s office or at the hospital. 

1. Bone marrow aspiration 

Bone marrow aspiration can be performed by numbing the back of the pelvic bone with local anesthesia. A needle is inserted into the bone and a syringe is used to remove a small amount of the liquid bone marrow. The bone marrow tissue is examined to check for the appearance, size, arrangement and shape of the cells and determine the presence of myeloma cells in the bone marrow. 

The liquid part of the bone marrow called the aspirate can also be sent for other tests such as immunohistochemistry and flow cytometry, and chromosome analyses, including karyotype and fluorescent in situ hybridization (also known as FISH).

2. Immunohistochemistry

It is a laboratory method that uses antibodies to check for the presence of certain antigens (markers) in the tissue sample. The sample is treated with special proteins that cause color change and help to identify myeloma cells. 

3. Flow cytometery

It is a technology that helps to analyze single cells or particles as they flow past multiple lasers while being suspended in a buffered salt based solution. The sample cells are treated with special proteins that stick only to certain cells. This in turn helps to identify if the cells are abnormal or cancerous cells.   

D. Imaging tests 

Along with the other chemical analysis and physical examination, the doctor may also recommend you to get a few imaging tests done. It will help provide a clear visual of the concerned/ affected organ or tissue.

1. X-rays scan

Multiple myeloma can cause tissue damage at the site of disease initiation. An X-ray produces images of the organs and confirms the presence of any tissue damage. It can be done to see if there is a suspicious area that might be cancer, or understand the spread of the cancer. 

2. Magnetic resonance imaging (MRI)

It is an imaging test that uses a magnetic field to take pictures of organs and structures inside the human body. An MRI can help understand the initiation and spread of the disease. 

3. CT scan

A CT scan, also known as computed tomography, is a machine that takes a series of x-rays to make a picture with minute details. The scan helps to image bones, blood vessels and soft tissues from different angles. It can also be used to guide a biopsy needle into an area of concern. 

If your doctor diagnoses you with multiple myeloma, the doctor will then use the information gathered to classify the disease into the respective stages - stage I, II, III or IV. 

Prevention Of Multiple Myeloma

As known, there aren't vaccines available for all the different cancers reported. There is no known way to prevent multiple myeloma. Scientists are still investigating if treating certain high risk factors such as smoldering multiple myeloma could help keep it from becoming active multiple myeloma. 

It is best advised to practice a healthy lifestyle, healthy eating habits, avoid smoking and excessive alcohol consumption to minimize chances of developing any form of cancer.

Specialist to Visit 

If you suspect that you may have multiple myeloma or suffer from reportes symptoms like unintentional weight loss, bone pain, increased calcium levels and fatigue, it is essential to seek expert medical advice from a team of: 

• Hematologist
• Hemato-oncologist
• Medical oncologist
• Oncosurgeon
• Bone marrow transplant specialist

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Treatment Of Multiple Myeloma

There are different treatment options available for multiple myeloma depending on the severity of the disease. The options can help ease the pain, reduce complications and also slow the progression of the disease. Common treatment options include:

Chemotherapy 

Chemotherapy medicines are the mainstay of treatment used to kill cancer cells. It is an aggressive form of drug therapy that helps to kill fast growing myeloma cells. In chemotherapy cycles, a certain number of days of treatment are followed by days of rest to allow the body to recover. Often, a combination of chemotherapy agents is used to treat cancer. 

Commonly used chemotherapeutics are:  

• Vincristine
• Daunorubicin
• Cytarabine
• Mercaptopurine
• Ifosfamide

Radiation therapy 

As the name suggests, radiation therapy uses radiation (high-energy rays similar to X-rays) to kill the cancer cells. The strong beams of energy kill the myeloma cells quickly enough in the specific sites.  

This therapy can also be used along with other treatment modalities such as chemotherapy and surgery. 

Targeted therapy

Targeted therapy medications help to block a chemical in the myeloma cells that destroys the protein and causes the cells to die. These drugs are given against a cancer cell-specific target. These targets are generally not present in normal dividing cells of our body therefore minimizing the adverse effects of the drug treatment. These therapies are generally expensive but more specific in their action.

Examples of targeted therapy include:

• Bortezomib
• Carfilzomib

Immunotherapy 

This therapy is being considered as the game changer in the cancer treatment world. Immunotherapy uses your immune system to fight cancer. Your body's disease-fighting immune system may not attack your cancer because the cancer cells produce proteins that help them hide from the immune system cells. Immunotherapy works by interfering with that process. 

Commonly used immunotherapeutics are:

• Belantamab is an antibody-drug conjugate that targets the BCMA pathway and is approved for subsets of patients with advanced multiple myeloma.

• Daratumumab is a monoclonal antibody that targets the CD38 pathway and is approved for subsets of patients with advanced multiple myeloma. 

• Elotuzumab is a monoclonal antibody that targets the SLAMF7 pathway and is approved for subsets of patients with advanced multiple myeloma.

• Isatuximab is a monoclonal antibody that targets the CD38 pathway and is approved for subsets of patients with advanced multiple myeloma. 

In addition to the FDA approved therapies, there are some second generation monoclonal antibodies targeting the CD38 and other targets, CAR- T cells and natural killer cells that are being investigated in clinical trials as well. 

Corticosteroids

These are medications that help to regulate the immune system and thereby help to control the inflammation. This steroidal therapy has been found to be effective against multiple myeloma as well. 

Here’s more on the do’s and don’ts to follow when using corticosteroids.
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Bone marrow transplant 

Also known as stem cell transplant, it is a special type of therapy for patients with certain cancer types such as multiple myeloma. Through this process, the unhealthy bone marrow cells are treated to kill the abnormal cells, and the healthy cells are filtered and transfused back into the patient. Bone marrow transplants have been successfully used to treat cancers, immune deficiency disorders and solid tumor cancers since the 1960s. 

Prior to being considered a candidate for bone marrow transplant, the doctors will evaluate if you are a good candidate for the same. You may be advised with some initial therapy which may include targeted therapy, immunotherapy, corticosteroids and even chemotherapy. 

Depending on the stage of the disease, age and overall health, a combination of different treatment options is often considered as well. 

Home-care For Multiple Myeloma

Patients with multiple myeloma may feel fatigued and are at an increased risk of frequent infections. Not to forget, the treatment regimen for multiple myeloma can be exhaustive and stressful as well. For instance, chemotherapy is often associated with several side-effects. 

Here are a few things one can keep in mind while taking care of themself or a loved one suffering from multiple myeloma. 

• Follow good hand hygiene. Avoid crowded places. Make a conscious effort to keep infections away.

• Eat fresh home-cooked meals and drink plenty of water or energy drinks daily.

• Eat small and frequent meals throughout the day.

• Embrace the side effects of chemotherapy such as loss of hair, skin discoloration, etc. Counseling and connecting with other people who are going through the same can help with the acceptance.

• Nausea and vomiting due to chemotherapy can be managed with medications or home remedies like sucking on peppermint lozenges.

• Meditation is a good way to practice relaxation. Try and incorporate it into your daily routine. 

• Engage in some sort of physical activity such as yoga or evening walks. It will help boost energy levels and help with symptoms of chronic fatigue.

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Complications Of Multiple Myeloma

Multiple myeloma can lead to several complications depending on the severity/stage of the disease and the effect of the treatment regime being undertaken. Common ones include:

Bone disorders 

Multiple myeloma affects the bones - usually the back, hips and ribs. It is a frequent dull pain which can get worse due to movement. Multiple myeloma can also cause thinning and weakening of bones causing frequent fractures. The spine and long bones (arms and legs) are most often affected.

Blood related problems

A large part of the Indian population with myeloma have been found to have anemia. Anemia is a condition in which one lacks healthy red blood cells to carry adequate oxygen to the body’s tissues. Anemia by itself also causes fatigue and weakness. Multiple myeloma affects the production of blood cells in the bone marrow leading to anemia. 

Frequent Infections 

Myeloma cells, infact cancer cells in general, inhibit the body’s ability to fight against infections. The disease weakens the immune system in general and therefore the patient becomes prone to frequent infections. 

Kidney damage

Multiple myeloma adversely affects the kidney function, therefore in case of severity, there is a chance of kidney damage or failure if left unaddressed or treated. Common signs of kidney impairment include weight loss, poor appetite, itchy skin, recurrent and continuous hiccups, tiredness and lack of energy.

Chronic pain 

Multiple myeloma patients may suffer from chronic pain due to several reasons including bone lesions, neuropathy, bone marrow examination or pain related to medications.

Hypercalcemia

A high level of calcium in the blood can be observed due to excessive calcium release from the affected bones in people with multiple myeloma. Common symptoms of hypercalcemia include extreme thirst, stomach pain, constipation, confusion and drowsiness. 

Here’s everything you need to know about hypercalcemia.
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Alternative Therapies For Multiple Myeloma

There aren't any alternative therapies known to treat multiple myeloma as such, however, it may help to cope with the stress, treatment regime and side effects of the disease. Some alternative therapies that will help cope with multiple myeloma while you are undergoing include:

Yoga 

Yoga helps to lower fatigue, reduce stress, improve muscle tension and improve physical functioning for cancer patients. In case of multiple myeloma, strength is considered more important compared to cardio activity. Therefore, yoga could serve as another mode of physical activity that could support your fight against the disease. 

Here are some of the health benefits of yoga.
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Music therapy 

Though there is no evidence to support that music therapy helps to treat cancer, it has been found to be a great psychological therapy for many cancer patients. Music has been found to relieve nausea and vomiting caused due to chemotherapy and other anti-cancer medications.

Exercise 

According to a 2013 study published in BMC Cancer, prescribed exercise programs for multiple myeloma patients are acceptable and safe. Undergoing multiple myeloma treatment generally leads to loss of lean muscle mass. Therefore, it is best advised to build lean mass and develop more metabolically active muscle mass during the recovery phase. You may require some advice and appropriate input from physical therapists. 

Massage therapy

Massage is considered as a relaxation and effective treatment for muscles and soft tissues, which is often what is needed for patients undergoing cancer treatment. It is a popular complementary therapy used by people living with cancer. Massage therapy helps to ease tension in the muscles, lowers stress and also helps to ease or release trigger points. 

Diet

A healthy diet is essential for good health and nutrition. Include fresh fruits, vegetables, herbs and spices in your daily diet that can help to boost your energy levels. Stay hydrated by including fluids such as fresh fruit juices and water in your daily dietary intake. Preference should be given to home cooked food. Avoid raw, uncooked and packaged food. 

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Aromatherapy

It is considered as a popular complementary treatment for cancer patients. It is defined as the use of essential oils from plants (trees, flowers or herbs) to improve the physical, mental and spiritual well being. Research suggests that aromatherapy helps to relieve anxiety, nausea and vomiting in cancer patients.  

Acupressure and acupuncture 

Acupressure and acupuncture techniques help combat pain, fatigue, and other symptoms. Studies suggest that acupuncture and acupressure can reduce the need to prescribe opioids for cancer pain. 

Living With Multiple Myeloma

Advancement in science and technology has led to better chances of survival for these patients. The fight against cancer can impact the emotional health of both the patient and their families, however it is worth the struggle if the patient manages to make it through.

Here are a few tips that can be of help for patients with multiple myeloma:

Join a support group

Staying positive during cancer treatment can be a lot easier if you have other people cheering you on. A support group can keep you motivated since the other participants will have their own insights into cancer treatment.

Surround yourself with positive people

When you’re feeling low, one of your friends or family members can provide some much-needed encouragement. When you’re feeling distressed, a trained mental health counselor can be of great help.

Learn and accept the diagnosis

Don’t be afraid to ask your healthcare team about anything you don’t understand. It is best to ask your doctor about your health and the condition.

Get rest

When you’re feeling anxious or depressed, or even just exhausted from your cancer treatment, get some sleep. Lack of sleep can make you feel even more anxious or despairing. You’re more likely to feel positive if you’re well rested.