Multiple myeloma

Multiple myeloma is a cancer that forms in a type of white blood cell called a plasma cell. Healthy plasma cells help you fight infections by making antibodies that recognize and attack germs.

In multiple myeloma, cancerous plasma cells accumulate in the bone marrow and crowd out healthy blood cells. Rather than produce helpful antibodies, the cancer cells produce abnormal proteins that can cause complications.

Treatment for multiple myeloma isn't always necessary right away. If the multiple myeloma is slow growing and isn't causing signs and symptoms, your doctor may recommend close monitoring instead of immediate treatment. For people with multiple myeloma who require treatment, a number of options are available to help control the disease.

Symptoms

Signs and symptoms of multiple myeloma can vary and, early in the disease, there may be none.

When signs and symptoms do occur, they can include:

• Bone pain, especially in your spine or chest
• Nausea
• Constipation
• Loss of appetite
• Mental fogginess or confusion
• Fatigue
• Frequent infections
• Weight loss
• Weakness or numbness in your legs
• Excessive thirst

When to see a doctor

Make an appointment with your doctor if you have any persistent signs and symptoms that worry you.

Causes

It's not clear what causes myeloma.

Doctors know that myeloma begins with one abnormal plasma cell in your bone marrow — the soft, blood-producing tissue that fills in the center of most of your bones. The abnormal cell multiplies rapidly.

Because cancer cells don't mature and then die as normal cells do, they accumulate, eventually overwhelming the production of healthy cells. In the bone marrow, myeloma cells crowd out healthy blood cells, leading to fatigue and an inability to fight infections.

The myeloma cells continue trying to produce antibodies, as healthy plasma cells do, but the myeloma cells produce abnormal antibodies that the body can't use. Instead, the abnormal antibodies (monoclonal proteins, or M proteins) build up in the body and cause problems such as damage to the kidneys. Cancer cells can also cause damage to the bones that increases the risk of broken bones.

A connection with MGUS

Multiple myeloma almost always starts out as a relatively benign condition called monoclonal gammopathy of undetermined significance (MGUS).

MGUS, like multiple myeloma, is marked by the presence of M proteins — produced by abnormal plasma cells — in your blood. However, in MGUS, the levels of M proteins are lower and no damage to the body occurs.

Risk factors

Factors that may increase your risk of multiple myeloma include:

• Increasing age. Your risk of multiple myeloma increases as you age, with most people diagnosed in their mid-60s.
• Male sex. Men are more likely to develop the disease than are women.
• Black race. Black people are more likely to develop multiple myeloma than are people of other races.
• Family history of multiple myeloma. If a brother, sister or parent has multiple myeloma, you have an increased risk of the disease.
• Personal history of a monoclonal gammopathy of undetermined significance (MGUS). Multiple myeloma almost always starts out as MGUS, so having this condition increases your risk.

Complications

Complications of multiple myeloma include:

• Frequent infections. Myeloma cells inhibit your body's ability to fight infections.
• Bone problems. Multiple myeloma can also affect your bones, leading to bone pain, thinning bones and broken bones.
• Reduced kidney function. Multiple myeloma may cause problems with kidney function, including kidney failure.
• Low red blood cell count (anemia). As myeloma cells crowd out normal blood cells, multiple myeloma can also cause anemia and other blood problems.

Diagnosis

Sometimes multiple myeloma is diagnosed when your doctor detects it accidentally during a blood test for some other condition. It can also be diagnosed if your doctor suspects you could have multiple myeloma based on your signs and symptoms.

Tests and procedures used to diagnose multiple myeloma include:

• Blood tests. Laboratory analysis of your blood may reveal the M proteins produced by myeloma cells. Another abnormal protein produced by myeloma cells — called beta-2-microglobulin — may be detected in your blood and give your doctor clues about the aggressiveness of your myeloma.

  Additionally, blood tests to examine your kidney function, blood cell counts, calcium levels and uric acid levels can give your doctor clues about your diagnosis.

• Urine tests. Analysis of your urine may show M proteins, which are referred to as Bence Jones proteins when they're detected in urine.

• Examination of your bone marrow. Your doctor may remove a sample of bone marrow for laboratory testing. The sample is collected with a long needle inserted into a bone (bone marrow aspiration and biopsy).

  In the lab, the sample is examined for myeloma cells. Specialized tests, such as fluorescence in situ hybridization (FISH) can analyze myeloma cells to identify gene mutations.

• Imaging tests. Imaging tests may be recommended to detect bone problems associated with multiple myeloma. Tests may include an X-ray, MRI, CT or positron emission tomography (PET).

Assigning a stage and a risk category

If tests indicate you have multiple myeloma, your doctor will use the information gathered from the diagnostic tests to classify your disease as stage I, stage II or stage III. Stage I indicates a less aggressive disease, and stage III indicates the most aggressive disease.

Your multiple myeloma may also be assigned a risk category, which indicates the aggressiveness of your disease.

Your multiple myeloma stage and risk category help your doctor understand your prognosis and your treatment options.

Treatment

If you're experiencing symptoms, treatment can help relieve pain, control complications of the disease, stabilize your condition and slow the progress of multiple myeloma.

Immediate treatment may not be necessary

If you have multiple myeloma but aren't experiencing any symptoms (also known as smoldering multiple myeloma), you might not need treatment right away. Immediate treatment may not be necessary for multiple myeloma that is slow growing and at an early stage. However, your doctor will regularly monitor your condition for signs that the disease is progressing. This may involve periodic blood and urine tests.

If you develop signs and symptoms or your multiple myeloma shows signs of progression, you and your doctor may decide to begin treatment.

Treatments for myeloma

Standard treatment options include:

• Targeted therapy. Targeted drug treatments focus on specific weaknesses present within cancer cells. By blocking these abnormalities, targeted drug treatments can cause cancer cells to die.
• Immunotherapy. 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.
• Chemotherapy. Chemotherapy uses drugs to kill cancer cells. The drugs kill fast-growing cells, including myeloma cells. High doses of chemotherapy drugs are used before a bone marrow transplant.
• Corticosteroids. Corticosteroid medications regulate the immune system to control inflammation in the body. They are also active against myeloma cells.

• Bone marrow transplant. A bone marrow transplant, also known as a stem cell transplant, is a procedure to replace your diseased bone marrow with healthy bone marrow.

  Before a bone marrow transplant, blood-forming stem cells are collected from your blood. You then receive high doses of chemotherapy to destroy your diseased bone marrow. Then your stem cells are infused into your body, where they travel to your bones and begin rebuilding your bone marrow.

• Radiation therapy. Radiation therapy uses high-powered energy beams from sources such as X-rays and protons to kill cancer cells. It may be used to quickly shrink myeloma cells in a specific area — for instance, when a collection of abnormal plasma cells form a tumor (plasmacytoma) that's causing pain or destroying a bone.

How treatments are used

Which combination of treatments you're likely to receive will depend on whether you're considered a good candidate for bone marrow transplant. This depends on the risk of your disease progressing, your age and your overall health.

• If you're considered a candidate for bone marrow transplant, your initial therapy will likely include a combination of treatments, such as targeted therapy, immunotherapy, corticosteroids and, sometimes, chemotherapy.

  Your blood stem cells will likely be collected after you've undergone a few months of treatment. You may undergo the bone marrow transplant soon after your cells are collected or the transplant may be delayed until after a relapse, if it occurs. In some situations, doctors recommend two bone marrow transplants for people with multiple myeloma.

  After your bone marrow transplant, you'll likely receive targeted therapy or immunotherapy as a maintenance treatment to prevent a recurrence of myeloma.

• If you're not considered a candidate for bone marrow transplant, your initial therapy will likely include a combination of treatments, such as targeted therapy, immunotherapy, corticosteroids and, sometimes, chemotherapy.

• If your myeloma recurs or doesn't respond to treatment, your doctor may recommend repeating another course of the treatment that initially helped you. Another option is trying one or more of the other treatments typically used as first line therapy, either alone or in combination.

  Research on a number of new treatment options is ongoing, and you may be eligible for a clinical trial in order to gain access to those experimental treatments. Talk to your doctor about what clinical trials may be available to you.

Treating complications

Because multiple myeloma can cause a number of complications, you may also need treatment for those specific conditions. For example:

• Bone pain. Pain medications, radiation therapy and surgery may help control bone pain.
• Kidney complications. People with severe kidney damage may need dialysis.
• Infections. Your doctor may recommend certain vaccines to prevent infections, such as the flu and pneumonia.
• Bone loss. Your doctor may recommend bone-building drugs to help prevent bone loss.
• Anemia. If you have persistent anemia, your doctor may recommend medications to increase your red blood cell count.

Alternative medicine

No alternative medicines have been found to treat multiple myeloma. But alternative medicine may help you cope with the stress and side effects of myeloma and myeloma treatment.

Talk to your doctor about your options, such as:

• Art therapy
• Exercise
• Meditation
• Music therapy
• Relaxation exercises
• Spirituality

Talk with your doctor before trying any of these techniques to make sure they don't pose any risks for you.

Coping and support

A cancer diagnosis can be shocking and devastating. With time, you'll find ways to cope with the stress and uncertainty of living with cancer. Until you find what works best for you, consider trying to:

• Learn enough to make decisions about your care. Learn enough about multiple myeloma so that you're able to participate in decisions about your treatment and care. Ask your doctor about your treatment options and their side effects.

  You may find additional help gathering information through your local library and online. Start with the National Cancer Institute and the International Myeloma Foundation.

• Maintain a strong support system. Having a strong support system can help you cope with issues and anxieties that might occur. Your friends and family may be willing to offer support.

  You might also find that support from a formal support group or others coping with cancer may be helpful. Friends you meet in support groups may be willing to share practical advice for coping with cancer and cancer treatment. Support groups are also available online.

• Set reasonable goals. Having goals helps you feel in control and can give you a sense of purpose. But don't choose goals you can't possibly reach. You may not be able to work a 40-hour week, for example, but you may be able to work at least part time. In fact, many people find that continuing to work during cancer treatment can be helpful in maintaining some normalcy.
• Take time for yourself. Eating well, relaxing and getting enough rest can help combat the stress and fatigue of cancer. Also, plan ahead for the downtimes when you may need to rest more or limit what you do.

Preparing for an appointment

If you have any signs or symptoms that worry you, make an appointment with your doctor.

If you're diagnosed with multiple myeloma, you'll likely be referred to a doctor who specializes in treating blood and bone marrow disorders (hematologist) or a doctor who specializes in treating cancer (oncologist).

Because appointments can be brief and because there's often a lot of ground to cover, it's a good idea to be well prepared. Here's some information to help you get ready and know what to expect from your doctor.

What you can do

• Note symptoms you're experiencing. If you have had signs and symptoms of illness or are just not feeling well, write down those details before your appointment. Your doctor will also want to know when you first noticed these symptoms and whether they've changed over time.
• List other medical conditions. Your doctor will be especially interested to know if you've been diagnosed with any other plasma disorders, such as monoclonal gammopathy of undetermined significance (MGUS).
• Make a list of your medications. Include any prescription or over-the-counter medications you're taking, as well as all vitamins, supplements and herbal remedies.
• Take a family member or friend along. Sometimes it can be difficult to remember all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Write down questions to ask your doctor.

Questions to ask your doctor at your initial appointment include:

• What may be causing my symptoms or condition?
• Are there any other possible causes?
• What kinds of tests do I need?
• What do you recommend for next steps in determining my diagnosis and treatment?
• Are there any restrictions that I need to follow in the meantime?

Questions to consider if your doctor refers you to a specialist include:

• Do I have multiple myeloma?
• What stage of myeloma do I have?
• Does my myeloma have any high-risk features?
• What are the goals of treatment in my case?
• What treatment do you recommend?
• I have these other health problems. How can I best treat them together with multiple myeloma?
• What are the possible side effects of treatment?
• If the first treatment isn't successful, what will be the next option?
• Am I a candidate for bone marrow transplantation?
• Do I need a medicine to strengthen my bones?
• What is the outlook for my condition?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Thinking about your answers ahead of time can help you make the most of your appointment. A doctor who sees you for possible multiple myeloma may ask:

• What are your symptoms, if any?
• When did you first begin experiencing symptoms?
• How have your symptoms changed over time?
• Do your symptoms include bone pain? Where?
• Do your symptoms include nausea, loss of appetite or weight loss?
• Do your symptoms include weakness or fatigue?
• Have you had repeated infections, such as pneumonia, sinusitis, bladder or kidney infections, skin infections, or shingles?
• Have you noticed any changes in your bowel habits?
• Have you been more thirsty or urinated more than usual?
• What else concerns you?
• Do you have any family history of plasma disorders such as MGUS?
• Have you been diagnosed or treated for any other medical conditions?
• Do you have a history of blood clots?
• What medications are you taking?

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