Holistic cancer care for multiple myeloma

Understanding multiple myeloma

Multiple myeloma (MM) is a blood cancer involving plasma cells, located in the bone marrow.

The site is primarily the bone marrow where the abnormal plasma cells grow, displacing normal blood cells. The abnormal plasma cells produce dysfunctional antibodies that are not effective in fighting bacteria and viruses, resulting in persistent infections and damage to vital organs.

The progression of this haematological disorder waxes and wanes over the years with several stages of active disease, followed by relapsed disease, symptomatic disease to stable asymptomatic disease.

Patients are followed-up frequently by their haematologist who will perform certain tests to assess the disease and any complications caused by MM.

If the disease is stable, no active treatment is required. If the level of MM antibodies is rising, treatment, such as chemo-immunotherapy or autologous stem cell transplant will be recommended.

There are several challenges, such as affordability and availability of therapy, radiotherapy, and diagnostic imaging.

Who is affected?

MM generally affects patients over the age of 60 years and is classically a disease of the elderly. However, the South African literature suggests patients are younger.

What are the symptoms?

Early in the disease, the symptoms may be absent or subtle. As the disease progresses, the symptoms include:

• Bone pain located to the spine, chest, or hips and unprovoked fractures.
• Non-specific symptoms, such as nausea, constipation, loss of appetite, tiredness related to anaemia.
• Recurrent infections, weakness, increased thirst, and increased urination.
• Swollen legs, difficulty passing urine and fatigability which are symptoms of renal dysfunction.
• Symptoms of hyperviscosity (blood becomes too thick) which may include headaches, visual change, bleeding, and strokes.

Should these symptoms be present, an urgent referral to a haematologist is warranted.

Causes and risk factors

The cause is uncertain; however, occupation exposures and viral exposure are thought to play a role.

The risk factors include:

• Advancing in age over 60 years
• Male gender
• A family history of MM with a genetic preponderance
• Pre-requisite states, such as monoclonal gammopathy of undetermined significance (MGUS)

Establishing a diagnosis

Once the diagnosis is suspected, the haematologist will perform a bone marrow aspirate and trephine biopsy (BMAT) with other specific haematological tests, such as flow cytometry, to assess the disease.

Molecular studies, such as cytogenetics and FISH, will be performed to establish the disease outcome. Chemistry studies, such as serum protein electrophoresis (SPEP) and immunofixation (IFE) will be performed, as well as renal function and calcium tests.

Radiological images (X-rays, MRI and/or PET/CT scans) of the axial skeleton will be requested to identify lytic lesions in the bone and fractures.

Once a complete diagnostic workup is performed, the performance status is assessed by the clinician, assessment of the cost involved of treatment, availability of therapy, and eligibility for autologous stem cell transplant is established prior to assigning a specific treatment plan.

Holistic cancer care plan

A patient is first analysed and those deemed asymptomatic with no organ damage or affectation are observed. The symptomatic patients are risk-stratified and classified based on transplant eligibility and availability of care.

The management is holistic and involves management of pain, hydration, renal failure, infections, high calcium, and anaemia in addition to other complications.

The pharmacological treatment involves using a combination of either a steroid, immunotherapy, targeted therapy, chemotherapy, monoclonal antibodies, radiotherapy, or autologous stem cell transplantation.

A patient is offered a stem cell transplant based on their functional status and prognosis of the disease. Generally, four to six cycles of combination treatment are offered in transplant eligible patients.

A patient is assessed periodically and if a relapse or refractory case is noted, the status is assessed in combination with the initial treatment regimens employed prior and potential for stem cell transplant.

Access and affordability

The regimen of therapy is primarily based on availability of care. Lenalidomide is a critical medication used in the management and maintenance of MM. South Africa has experienced significant fluctuations in the availability of this immunomodulatory agent.  In 2016, pricing of this drug was approximately R75 000 per month; this surge was attributed to patent protections and monopolistic market for new entities. The entry of generic competitors introduced more affordable options with prices dropping to R1 150 per month in the public sector. Additionally, local manufacturers further reduced the prices per month.

These developments highlight the impact of market competition, patent regulations, and local manufacturing on the pricing of essential cancer medications in South Africa.

Supportive care

The supportive care of a patient with MM is paramount in ensuring a successful outcome. This may include referral for palliative care, physiotherapy, and addressing the psychosocial model through the assistance of a social worker and psychologist.

There are several support groups and frameworks which may exist in the South African setting, such as CANSA, BLOODSA, Bristol Myers and Squibb Foundation and Cancer Alliance.