Multiple myeloma management revolutionised

The relatively recent ease of access to lenalidomide in South Africa has revolutionised multiple myeloma management. Dr Zeenat Moorad expands on this.

Multiple myeloma is a blood cancer that develops from a special type of white blood cell, called a plasma cell, in the bone marrow. Plasma cells are part of the immune system, and make proteins called antibodies (immunoglobulins) that attack and kill bacteria and viruses, protecting against infection.

In multiple myeloma, too many abnormal plasma cells of the same type crowd the bone marrow, reducing space for the development of normal white cells, red cells, and platelets.

In most cases, the cause of multiple myeloma is not known. Approximately 6 000 people are diagnosed with multiple myeloma in the UK each year, with 45% of new cases being people aged 75 or more. Multiple myeloma is rare in people less than 40 years old and males are affected more than women.

The basics of multiple myeloma

Multiple myeloma develops when changes in the DNA of the plasma cells occur. DNA is the instruction for the cell, so it knows what to do and when. The change happens to the DNA when the bone marrow is making new plasma cells. The abnormal plasma cell in turn produces more abnormal plasma cells (the myeloma cells) which produce abnormal types of antibodies called paraproteins. The abnormal antibodies (also known as monoclonal proteins or monoclonal spike) do not work normally, often resulting in recurrent and severe infections.

Paraproteins are found in the blood and urine. One part of the paraprotein is called the light chain, also known as the Bence-Jones protein. The body gets rid of the light chain in the urine. Blood and urine tests are used to detect these light chains to diagnose and monitor multiple myeloma.

The increase in abnormal antibodies thicken the blood, resulting in various symptoms, such as dizziness, headaches, and chest pain.

Red blood cells carry oxygen around the body. When there are fewer red blood cells, anaemia develops. Symptoms of anaemia include: fatigue, weakness, tiredness, and breathlessness.

Myeloma cells can also damage nearby bones, causing bone pain and fractures (which may result after minimal trauma). Bone injury causes calcium to be released into the bloodstream. High calcium levels may result in increased thirst, dehydration, constipation, and confusion. Myeloma cells can also damage the kidneys.

There are different types of myeloma named after the abnormal immunoglobulin (paraprotein) made by the myeloma cells; IgG is the most common type. The next most common is IgA and light chain only. IgM, IgD and IgE are very rare.

Treatment

Treatment of multiple myeloma requires a multi-disciplinary team, with psychological support as well as medical support, and where necessary, surgical support for bone fractures, etc.

Medical management includes:

• Treatment of pain
• Dehydration
• Infections
• Anaemia
• Bone disease

The main treatments for the myeloma itself, include targeted cancer drugs, chemotherapy, and steroids.

The powers of lenalidomide

Lenalidomide is an immune modulating cancer drug used in multiple myeloma in combination with other drugs, such as bortezomib (proteasome inhibitor) and/or dexamethasone or melphalan and prednisolone. It’s used in the initiation phase as well as maintenance treatment. The relatively recent ease of access to lenalidomide in South Africa has revolutionised myeloma management dramatically improving outcomes and enhancing the quality of life for patients

Lenalidomide works by:

• Halting cancer cell development
• Preventing blood vessels growing in the cancer and cutting of blood supply to the cancer
• Stimulating part of the immune system to attack the cancer cells

The standard dose of lenalidomide is 25mg taken orally once a day, on days 1 – 21 of a 28-day cycle. Days 22 – 28 are rest days. Lenalidomide is generally well-tolerated. Dose reductions may be necessary should patients experience side effects. Due to the risk of blood clotting (venous thromboembolism), patients must be on acetylsalicylic acid or anticoagulation if the risk of clotting is higher.

Other side effects include:

• Decrease in blood counts
• Gastrointestinal symptoms
• Skin rash
• Numbness and tingling of fingers and toes

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