Multiple Myeloma
Myeloma usually develops at a number of different sites within the body. This cancer is therefore called multiple myeloma. The most common sites for multiple myeloma are the
pelvis, spine, rib cage, skull, shoulders and hips.

Signs and symptoms
Multiple myeloma may not cause symptoms in its early stages. Symptoms can include: bone pain (this may be a result of bone damage)  bleeding/bruising problems (this can be a result of impaired healing)  anaemia, tiredness, weakness, shortness of breath, infection (as a result of not having enough healthy white blood cells) confusion and constipation.

Multiple myeloma affects certain white blood cells called plasma cells. To understand multiple myeloma, it is helpful to know about normal cells, especially plasma cells, and what happens when they become cancerous.

Normal Cells
The body is made up of many kinds of cells. Each type of cell has special functions. Normal cells are produced in an orderly, controlled way as the body needs them. This process keeps us healthy.
Plasma cells and other white blood cells are part of the immune system, which helps protect the body from infection and disease. All white blood cells begin their development in the bone marrow, the soft, spongy tissue that fills the centre of most bones. Certain white blood cells leave the bone marrow and mature in other parts of the body. Some of these develop into plasma cells when the immune system needs them to fight substances that cause infection and disease.

Plasma cells produce antibodies, proteins that move through the bloodstream to help the body get rid of harmful substances. Each type of plasma cell responds to only one specific substance by making a large amount of one kind of antibody. These antibodies find and act against that one substance. Because the body has many types of plasma cells, it can respond to many substances.

Myeloma Cells
When cancer involves plasma cells, the body keeps producing more and more of these cells. The unneeded plasma cells -- all abnormal and all exactly alike -- are called myeloma cells.

Myeloma cells tend to collect in the bone marrow and in the hard, outer part of bones. Sometimes they collect in only one bone and form a single mass, or tumour, called a plasmacytoma. In most cases, however, the myeloma cells collect in many bones, often forming many tumours and causing other problems. When this happens, the disease is called multiple myeloma. This booklet deals mainly with multiple myeloma.

It is important to keep in mind that cancer is classified by the type of cell or the part of the body in which the disease begins. Although plasmacytoma and multiple myeloma affect the bones, they begin in cells of the immune system. These cancers are different from bone cancer, which actually begins in cells that form the hard, outer part of the bone. This fact is important because the diagnosis and treatment of plasmacytoma and multiple myeloma are different from the diagnosis and treatment of bone cancer.

Because people with multiple myeloma have an abnormally large number of identical plasma cells, they also have too much of one type of antibody. These myeloma cells and antibodies can cause a number of serious medical problems:

As myeloma cells increase in number, they damage and weaken bones, causing pain and sometimes fractures. Bone pain can make it difficult for patients to move.

When bones are damaged, calcium is released into the blood. This may lead to hypercalcaemia -- too much calcium in the blood. Hypercalcaemia can cause loss of appetite, nausea, thirst, fatigue, muscle weakness, restlessness, and confusion.

Myeloma cells prevent the bone marrow from forming normal plasma cells and other white blood cells that are important to the immune system. Patients may not be able to fight infection and disease. The cancer cells also may prevent the growth of new red blood cells, causing anaemia. Patients with anaemia may feel unusually tired or weak. Multiple myeloma patients may have serious problems with their kidneys. Excess antibody proteins and calcium can prevent the kidneys from filtering and cleaning the blood properly.

Symptoms of multiple myeloma depend on how advanced the disease is. In the earliest stage of the disease, there may be no symptoms. When symptoms do occur, patients commonly have bone pain, often in the back or ribs. Patients also may have broken bones, weakness, fatigue, weight loss, or repeated infections. When the disease is advanced, symptoms may include nausea, vomiting, constipation, problems with urination, and weakness or numbness in the legs. These are not sure signs of multiple myeloma; they can be symptoms of other types of medical problems. A person should see a doctor if these symptoms occur. Only a doctor can determine what is causing a patient's symptoms.

Multiple myeloma may be found as part of a routine physical exam before patients have symptoms of the disease. When patients do have symptoms, the doctor asks about their personal and family medical history and does a complete physical exam. In addition to checking general signs of health, the doctor may order a number of tests to determine the cause of the symptoms. If a patient has bone pain, x-rays can show whether any bones are damaged or broken. Samples of the patient's blood and urine are checked to see whether they contain high levels of antibody proteins called M proteins. The doctor also may do a bone marrow aspiration and/or a bone marrow biopsy to check for myeloma cells. In an aspiration, the doctor inserts a needle into the hip bone or breast bone to withdraw a sample of fluid and cells from the bone marrow. To do a biopsy, the doctor uses a larger needle to remove a sample of solid tissue from the marrow. A pathologist examines the samples under a microscope to see whether myeloma cells are present.

Treatment depends on the extent of the cancer and the patient's symptoms. The doctor also considers the person's age and general health. The doctor may want to discuss the patient's case with other doctors who treat multiple myeloma. Also, the patient may want to talk with the doctor about taking part in a research study of new treatment methods. Such studies, called clinical trials, are designed to improve the treatment of this type of cancer. These studies are discussed in the Treatment Studies section. These are some questions patients may want to ask the doctor:

  • What are my treatment choices?
  • Would a clinical trial be appropriate for me?
  • What are the expected benefits of treatment?
  • What are the risks and possible side effects of treatment?
  • If I have pain, how will you help me?
  • Will I need to change my normal activities?
  • How often will I need to have checkups?

Many people find it helpful to make a list of their questions before they see the doctor. Taking notes can make it easier to remember what the doctor says. Some patients also find that it helps to have a family member or friend with them when they see the doctor -- to take part in the discussion or just to listen.

Before Treatment
Treatment decisions for multiple myeloma are complex. Before starting treatment, the patient might want a second doctor to review the diagnosis and treatment plan. A short delay usually does not reduce the chance that treatment will be effective. There are a number of ways to find a doctor for a second opinion:

The patient's doctor may be able to suggest a doctor who treats multiple myeloma. Doctors who specialize in treating this disease include oncologists, haematologists, and radiation oncologists.

Treatment Methods
Plasmacytoma and multiple myeloma are very hard to cure. Although patients who have a plasmacytoma may be free of symptoms for a long time after treatment, many eventually develop multiple myeloma. For those who have multiple myeloma, treatment can improve the quality of a patient's life by controlling the symptoms and complications of the disease.

People who have multiple myeloma but do not have symptoms of the disease usually do not receive treatment. For these patients, the risks and side effects of treatment are likely to outweigh the possible benefits. However, these patients are watched closely, and they begin treatment when symptoms appear. Patients who need treatment for multiple myeloma usually receive chemotherapy and sometimes radiation therapy.

Chemotherapy is the use of drugs to treat cancer. It is the main treatment for multiple myeloma. Doctors may prescribe two or more drugs that work together to kill myeloma cells. Many of these drugs are taken by mouth; others are injected into a blood vessel. Either way, the drugs travel through the bloodstream, reaching myeloma cells all over the body. For this reason, chemotherapy is called systemic therapy.

Anticancer drugs often are given in cycles -- a treatment period followed by a rest period, then another treatment and rest period, and so on. Most patients take their chemotherapy at home, as outpatients at the hospital, or at the doctor's office. However, depending on their health and the drugs being given, patients may need to stay in the hospital during treatment.

Radiation therapy (also called radiotherapy) uses high-energy rays to damage cancer cells and stop them from growing. In this form of treatment, a large machine aims the rays at a tumour and the area close to it. Treatment with radiation is local therapy; it affects only the cells in the treated area.

Radiation therapy is the main treatment for people who have a single plasmacytoma. They usually receive radiation therapy every weekday for 4 to 5 weeks in the outpatient department of a hospital or clinic.

People who have multiple myeloma sometimes receive radiation therapy in addition to chemotherapy. The purpose of the radiation therapy is to help control the growth of tumours in the bones and relieve the pain that these tumours cause. Treatment usually lasts for 1 to 2 weeks.

Treatment Studies

Because multiple myeloma is so hard to control, many researchers are looking for more effective treatments. They also are looking for treatments that have fewer side effects and for better ways to care for patients who have complications caused by this disease. When laboratory research shows that a new method has promise, doctors use it to treat cancer patients in clinical trials. These trials are designed to find out whether the new approach is both safe and effective and to answer scientific questions. Patients who take part in clinical trials may have the first chance to benefit from improved treatment methods, and they make an important contribution to medical science.

Many clinical trials of new treatments for multiple myeloma are under way. In some studies, doctors are testing new drugs and new drug combinations. In others, they are using chemotherapy along with biological therapy, treatment with substances that boost the immune system's response to cancer.

Researchers also are testing new approaches to cancer treatment that allow the use of very high doses of anticancer drugs, sometimes along with radiation. Doctors believe that higher doses of anticancer drugs and radiation might be more effective than the usual doses in destroying myeloma cells. However, higher doses also cause greater damage to healthy bone marrow. New approaches to treatment may help the healthy marrow recover or may allow doctors to replace marrow that is destroyed.

Side Effects of Treatment
The methods used to treat multiple myeloma are very powerful. Treatment can help patients feel better by relieving symptoms such as bone pain. However, it is hard to limit the effects of therapy so that only cancer cells are destroyed. Because healthy cells also may be damaged, treatment can cause unpleasant side effects.

The side effects that patients have during cancer treatment vary for each person. They may even be different from one treatment to the next. Doctors try to plan treatment to keep side effects to a minimum. They also monitor patients very carefully so they can help with any problems that occur.

The side effects of chemotherapy depend on the drugs that are given. In general, anticancer drugs affect rapidly growing cells, such as blood cells that fight infection, cells that line the digestive tract, and cells in hair follicles. As a result, patients may have lower resistance to infection, loss of appetite, nausea, vomiting, or mouth sores. Patients also may have less energy and may lose their hair. One drug used to treat multiple myeloma, called prednisone, may cause swelling of the face and feet, burning indigestion, mood swings, restlessness, and acne. The side effects of chemotherapy usually go away over time after treatment stops.

During radiation therapy, the patient may be more tired than usual. Resting is important, but doctors usually advise patients to stay as active as they can. Also, the skin in the treated area may become red or dry. The skin should be exposed to the air but protected from the sun, and patients should avoid wearing clothes that rub the treated area. They should not use any lotion or cream on the skin without the doctor's advice. Patients may have other side effects, depending upon the areas treated. For example, radiation to the lower back may cause nausea, vomiting, or diarrhoea because the lower digestive tract is exposed to radiation. The doctor often can prescribe medicine or suggest changes in diet to ease these problems. Side effects usually disappear gradually after radiation therapy is over.

Loss of appetite can be a problem for patients with multiple myeloma. People may not feel hungry when they are uncomfortable or tired. Some of the common side effects of cancer treatment, such as nausea and vomiting, can also make it hard to eat. Yet patients who eat well often feel better and have more energy, so good nutrition is important. Eating well means getting enough calories and protein to prevent weight loss, regain strength, and rebuild normal tissues. Many patients find that having several small meals and snacks during the day works better than having three regular meals.

Supportive Care
The complications of multiple myeloma can affect many parts of the body. Chemotherapy and radiation therapy often can help control complications such as pain, bone damage, and kidney problems. However, from time to time, most patients need additional treatment to manage these and other problems caused by the disease. This type of treatment, called supportive care, is given to improve patients' comfort and quality of life.

Patients with multiple myeloma frequently have pain caused by bone damage or by tumours pressing on nerves. Doctors often suggest that patients take pain medicine and/or wear a back or neck brace to help relieve their pain. Some patients find that techniques such as relaxation and imagery can reduce their pain.

Preventing or treating bone fractures is another important part of supportive care. Because exercise can reduce the loss of calcium from the bones, doctors and nurses encourage patients to be active, if possible. They may suggest appropriate forms of exercise. If a patient has a fracture or a breakdown of certain bones, especially those in the spine, a surgeon may need to operate to remove as much of the cancer as possible and to strengthen the bone.

Patients who have hypercalcaemia may be given medicine to reduce the level of calcium in the blood. They also are encouraged to drink large amounts of fluids every day; some may need intravenous (IV) fluids. Getting plenty of fluids helps the kidneys get rid of excess calcium in the blood. It also helps prevent problems that occur when calcium collects in the kidneys.

If the kidneys aren't working well, dialysis or plasmapheresis may be necessary. In dialysis, the patient's blood passes through a machine that removes wastes, and the blood is then returned to the patient. Plasmapheresis is used to remove excess antibodies produced by the myeloma cells. This process thins the blood, making it easier for the kidneys and the heart to function.

Multiple myeloma weakens the immune system. Patients must be very careful to protect themselves from infection. It is important that they stay out of crowds and away from people with colds or other infectious diseases. Any sign of infection (fever, sore throat, cough) should be reported to the doctor right away. Patients who develop infections are treated with antibiotics or other drugs.

Patients who have anaemia may have transfusions of red blood cells. Transfusions can help reduce the shortness of breath and fatigue that can be caused by anaemia.

Followup Care

Regular follow-up is very important for anyone who has multiple myeloma. Checkups generally include a physical exam, x-rays, and blood and urine tests. Regular follow-up exams help doctors detect and treat problems promptly if they should arise. It is also important for the patient to tell the doctor about any new symptoms or problems that develop between checkups.