What is blood?
Multiple myeloma is a cancer affecting plasma cells, which are a type of white blood cell.
Blood is pumped around your body to supply oxygen and nutrients to your tissues and take away waste products. It is made up of:
- red cells - carry oxygen from your lungs to the rest of your body
- white cells - fight infection
- platelets - form clots to stop bleeding.
The different kinds of blood cells are made by the bone marrow (the spongy part in the centre of bones). The bone marrow contains stem cells, which are primitive blood cells that develop into either red cells, white cells or platelets. When a stem cell matures, in most cases it is released into the bloodstream.
Plasma cells, which are affected in multiple myeloma, are a type of white blood cell that normally remains in the bone marrow. They:
- form part of the immune system
- help fight infection by making proteins called antibodies, which attack bacteria and viruses that infect the body.
What is multiple myeloma?
- Myeloma starts in the bone marrow. Because bone marrow is found in multiple areas of the body (e.g. in the spine, skull and pelvis), the disease is often called multiple myeloma.
- The DNA (genetic code) of the plasma cells has been damaged, so they become malignant or cancerous. These abnormal plasma cells are known as myeloma cells.
- Myeloma cells divide and expand within the bone marrow, crowding out the rest of the bone marrow so it can't make enough healthy blood cells.
- Myeloma weakens the immune system and the level of normal antibodies is reduced.
- Myeloma cells make one kind of antibody -- known as M-protein, monoclonal protein or paraprotein. This antibody is faulty and has no useful function.
- M-protein is in the blood of most people with myeloma. Part of this antibody is found in the urine of some patients, where it is called Bence Jones protein.
- There are different types of myeloma, which are classified according to the type of M-protein present. There are also different stages of myeloma, which indicates the amount of myeloma present and can help determine a person’s prognosis.
- Myeloma can spread from the bone marrow into the bone itself.
How common is it?
- Multiple myeloma is not a common illness.
- It represents only 1% of all cancer diagnoses in Australia.
- 428 people were diagnosed with myeloma in NSW in 2005.
- Myeloma usually occurs in people aged 60 and over. Only 20% of people with myeloma are under 60. It is rare in people under 40.
- Myeloma is becoming more common in younger adults, but the reason for this is unclear.
- The disease is becoming more common in the elderly, due, in part to the ageing population.
Causes of multiple myeloma
The cause of multiple myeloma is unknown. However, it is more common in older people, men and some racial groups (such as African-Americans). Increased risk for myeloma has also been linked to:
- certain chemicals (e.g. agricultural chemicals, dioxins)
- radiation
- viruses (such as HIV)
- obesity
- smoking
- family history of other blood or lymphatic cancers.
Myeloma is not hereditary, which means it does not run in families. It is rare for more than one person in a family to be affected. However, there is an increased risk for developing multiple myeloma among people who have a family history of other blood and lymphatic cancers.
Symptoms
Multiple myeloma can cause a range of symptoms because of its effects on the bone marrow, bones and kidneys.
Abnormal blood tests
- The myeloma cells may stop the bone marrow from making enough normal blood cells, resulting in irregular blood counts (levels of blood cells).
- Low red blood cell levels cause anaemia, which may make you weak, tired and pale, and have breathlessness or a racing heart.
- Low platelet levels can cause bleeding problems such as heavy nosebleeds or easy bruising.
- Low levels of white blood cells and normal antibodies cause recurrent infections.
Bone damage
- Myeloma produces substances that can cause soft, brittle bones (osteoporosis) or destroy areas of bone (lytic lesions).
- When bones are damaged, they are more likely to break or fracture, causing pain and restricting mobility.
- Damaged bones may release calcium into the blood, causing hypercalcaemia (high levels of calcium in the blood), which can lead to drowsiness and renal (kidney) failure.
Other problems
- If a large amount of M-protein is present, it can damage the kidneys as it passes through them into the urine.
- Kidney failure and weight loss are less common symptoms of myeloma.
Amyloidosis
Some people with multiple myeloma also have a condition called amyloidosis. This is a build-up in the body of a fibrous protein called amyloid tissue, which can sometimes affect the functioning of different organs. In many people the condition does not cause any symptoms.
Diagnosis
Different tests are needed to diagnose multiple myeloma. The tests may be uncomfortable, but they will enable your specialist, usually a haematologist, to determine the type of myeloma you have, how it is affecting you, and the best treatment plan for you.
Blood and urine tests
Blood test
- Looks for M-protein, the abnormal antibody made by myeloma cells and often found in high amounts.
- Can determine the type of M-protein present.
- Blood tests can show whether you have anaemia, kidney impairment or a high level of calcium in the blood.
Urine test
A urine test is done to check for the Bence Jones protein, which is a part of the M-protein antibody. It is found in around 30% of people with myeloma.
Not everybody with M-protein in the blood or urine has multiple myeloma. Other conditions where M-protein is present include inflammatory diseases, chronic infection, and a condition called MGUS (Monoclonal Gammopathy of Undetermined Significance). People with MGUS do not have symptoms and the majority remain well for years, but some may develop myeloma or related diseases in later years.
Bone x-rays
- X-rays take pictures of the inside of your body. The procedure is painless.
- Bone x-rays (skeletal surveys) can show thinning and softening of the bones (osteoporosis).
- They can also show areas of bone destruction (lytic lesions).
CT (computerised tomography) scan
- A test that uses x-rays to take cross-section pictures of the inside of your body.
- You will lie flat on a table while the CT scanner, which is large and round like a doughnut, moves around you and takes pictures.
- You may have an injection of dye into your veins before the scan -- this will make pictures clearer.
- The scan is painless and takes between 10 and 30 minutes.
- Used to review a part of the body in more detail or to identify areas of bone damage that may not show up on a standard x-ray.
MRI (magnetic resonance imaging) scan
- Uses a combination of magnetism and radio waves to build up detailed cross-section pictures of your body.
- Involves lying on a table inside a metal cylinder - a large magnet - that is open at both ends.
- You may have an injection of dye into your veins before the scan -- this will make the pictures clearer.
- The scan is painless.
- Some people find lying in the cylinder noisy and claustrophobic. If you feel uncomfortable, let your doctor or nurse know.
- Shows whether myeloma is present inside and outside the bones.
Caution: You must tell the doctor if you have ever had an allergy to dyes or iodine, as this will affect whether contrast is used for a CT scan or MRI. People who have a pacemaker cannot have an MRI, due to the effect of the magnet.
Bone marrow biopsy
- This procedure is done under a local or general anaesthetic.
- A thin needle is used to remove a small amount of bone marrow from the pelvis, hip or breastbone.
- May be uncomfortable. Mild painkillers or a sedative can help ease the discomfort.
- Enables cells from the bone marrow to be examined.
Cytogenetic tests
Chromosomes in cells taken from the bone marrow or from blood samples are examined to help make a diagnosis and decide on treatment.
Prognosis
Prognosis is the expected outcome of a disease. You need to discuss this with your doctor. Only someone who knows your medical history can tell you what to expect and the treatment options that are best for you.
For most people with multiple myeloma, the disease is not curable, but it is treatable and can be controlled.
The typical course of the disease is multiple episodes of disease activity, followed by a plateau phase (when the disease is under control). When the disease comes back (relapses), more treatment will be needed, which may result in another plateau phase. Some people's prognosis improves significantly with a bone marrow or blood stem cell transplant, but this is only suitable for less than 5% of patients.
Which health professionals will I see?
Your GP will arrange the first tests to check out your symptoms. This can be a worrying and tiring time, especially if you need several tests.
If these tests do not rule out cancer, you will usually be referred to a haematologist, a doctor who specialises in diseases of the blood, the lymphatics and bone marrow. This specialist will investigate your symptoms, make a diagnosis and advise you about treatment options.
Other health professionals you may see include:
- radiation oncologist - prescribes and coordinates the course of radiotherapy
- nurses - give the course of treatment and support and assist you through all stages of your treatment
- dietician - recommends the best eating plan to follow while you are in treatment and recovery
- social worker, physiotherapist and occupational therapist - help you to resume normal activities and link you to support services.
Treatment
After the diagnosis, the most important decision is whether treatment is needed straight away. Early-stage myeloma, also called asymptomatic or smouldering myeloma, does not need to be treated, as early treatment has not been shown to be of any benefit. People with smouldering myeloma will need regular checkups, and treatment will be started if problems occur.
The main forms of treatment for multiple myeloma are a combination of chemotherapy, other medications and radiotherapy (x-ray treatment).
Chemotherapy
- Chemotherapy uses drugs to kill or slow the growth of leukaemia cells.
- It is usually given by injection into a vein (intravenously), under the skin (subcutaneously) or as tablets.
- The most commonly used chemotherapy drugs for multiple myeloma are melphalan and cyclophosphamide. Other drugs are adriamycin, bis-chloronitrosourea (BCNU) and vincristine.
- A hospital stay is sometimes necessary but it is usually short.
Thalidomide and related drugs
- Thalidomide is an old drug with new uses: it is now known to have anti-cancer effects, particularly for multiple myeloma.
- It is thought to work by blocking the blood supply to the cancer and by altering the body's immune response to cancer.
- New types of thalidomide-like drugs that cause fewer side effects are being developed.
Corticoid steroids
- Drugs that are similar to a hormone produced by the body's adrenal glands.
- Are commonly used to relieve swelling and inflammation.
- Have been shown to act against myeloma cells.
- Include prednisone, prednisolone or dexamethasone.
Interferon alfa
- Used to treat certain cancers and viral infections.
- It is given as an injection under the skin several times a week.
- It may be used after chemotherapy or a bone marrow transplant to prolong control of the disease.
Bisphosphonates
- A new class of drugs that are useful in myeloma
- Prevent and reduce complications of bone disease.
- Prevent a dangerous rise in blood calcium levels.
- Improve well-being and may prolong control of the disease.
- Can be taken as tablets or injections.
Bortezomib
- Bortezomib (Velcade) belongs to a class of drugs that interfere with the function of myeloma cells, causing them to die.
- The drug is available for people who have had initial treatment but the myeloma is still progressing.
Radiotherapy
- A painless procedure using x-rays to kill myeloma cells or injure them so they cannot multiply.
- It is used to help relieve some symptoms such as bone pain.
- Your radiation oncologist and haematologist will discuss the type of radiotherapy and the number of treatments you need.
- You will probably have treatment for a few days each week for several weeks.
Plasma exchange
- Sometimes needed if the level of abnormal protein in the blood is very high, is interfering with blood circulation by making the blood thicker (hyperviscosity), or is damaging the body.
- Involves the separation and removal of plasma (which contains the abnormal protein) from the blood.
- A needle is placed into a vein in each arm. Blood is slowly removed from one arm and then passed through a separating machine. The healthy portion of the blood, plus new replacement plasma, is then put back in via the other arm.
- Usually takes a few hours.
Bone marrow or stem cell transplant
- A transplant of stem cells is an increasingly common treatment option for some myeloma patients.
- It enables you to receive high doses of chemotherapy to kill the myeloma cells.
- The goal of a transplant is to extend your life and improve your quality of life.
- It is not suitable for everyone because of the risks associated with the high-dose chemotherapy given before the transplant (e.g. infection or excessive bleeding).