Multiple myeloma

Multiple (plasma cell) myeloma is cancer of the plasma cells in bone marrow. Bone marrow is the soft tissue inside bones where blood cells are made. Widespread growth of the malignant (cancerous) plasma cells in the bone marrow may leave little room for normal blood cells. This causes a range of problems including weak bones, anaemia and reduced immunity.

Multiple myeloma is rarely seen in people under 40 years of age. About 300 Victorians are diagnosed with multiple myeloma each year. There is no cure, but the condition can usually be managed successfully for several years. Many new drugs and treatment strategies have been approved for the treatment of multiple myeloma and this has improved the outlook for many people with this condition.

Blood is made up of plasma

Blood is mostly made up of plasma. Within the plasma are:

• Red blood cells – that carry oxygen around the body
• White blood cells – that fight disease and infection
• Platelets – that help to stop bleeding when it starts (assist with blood clotting).

The plasma cells in healthy people are an important part of the immune system and develop from white blood cells called lymphocytes. These cells make antibodies that help fight infections.

Effects on the immune system

When a person has multiple myeloma, there is a large increase in the malignant (cancerous) plasma cells and a reduction in the normal plasma cells. The malignant plasma cells are inside the bone marrow. This means that there is no longer the space necessary to make normal white cells, red cells and platelets.

As a result, the person has fewer red and white cells. The low red cell count causes anaemia (with symptoms such as tiredness, lethargy and shortness of breath on exertion). The low white cell count may mean the person is less able to fight infections and respond appropriately to vaccinations.

Effects on bones and kidneys

The malignant plasma cells also produce different substances that cause the bone to become thin, weak and more likely to break. This may be associated with an increase in the level of calcium in the blood. Abnormal proteins produced by the malignant cells may affect the kidneys so that they cannot filter and clean the blood properly.

Symptoms of multiple myeloma

In its early stages, myeloma may not cause symptoms. When they do occur, symptoms include:

• Bone pain, particularly in the back and ribs
• Easily broken bones (fractures)
• Tiredness, lethargy or shortness of breath on exertion – usually caused by too few red blood cells in the body (anaemia)
• Easy bruising or bleeding – due to low platelet numbers
• Bleeding from the nose or gums
• Repeated infections or infections that are hard to get rid of
• Thirst, nausea, vomiting or constipation due to high calcium levels in the body.

Diagnosis of multiple myeloma

Multiple myeloma is diagnosed using a number of tests including:

• Blood tests – to check the levels of normal blood cells, calcium levels, renal function and for the presence of M-protein and serum light chains (made by myeloma cells)
• Urine tests – to detect the presence of M-protein
• Whole body low dose CT scans or CT skeletal survey – to test for any myeloma bone damage or fractures
• Bone marrow tests (aspirate and biopsy) – to look at the cells in the bone marrow and count the number of plasma cells. The biopsy involves a small amount of fluid and a small core of bone marrow being removed. The presence of abnormal chromosomes may also be determined.

Test results can take a few days to come back. It is very natural to feel anxious while waiting to get your results. It can help to talk to a close friend or relative about how you are feeling. You could also contact your local cancer information and support service.

Treatment for multiple myeloma

If treatment is recommended, it may include:

• Chemotherapy – cancer-killing drugs are given, either as injections or tablets.
• Radiotherapy– x-rays are used to target and destroy cancer cells. Radiotherapy also helps to relieve pain and reduce the risk of further bone fractures.
• Steroids – commonly given by injection or as tablets with chemotherapy, help make the treatment more successful.
• Thalidomide – is thought to work by slowing blood vessel growth around the abnormal plasma cells. It is taken as tablets.
• Lenalidomide – is thought to work by killing myeloma cells and altering the immune system. It is taken as tablets.
• Bortezomib – is thought to work by killing myeloma cells. It is taken as an injection under the skin.
• Stem cell transplantation – all blood cells come from stem cells in the bone marrow. High doses of chemotherapy can damage normal cells, so stem cells are removed from the bone marrow before higher doses Bisphosphonates – are given to treat the high calcium levels, strengthen bones and reduce pain. They can be given as injections or taken as tablets.
• Surgery – weak or thin bones may need to be strengthened with plates, pins or screws.
• Plasma exchange (plasmapheresis) – can be used to remove the abnormal protein produced by the myeloma cells. This stops the blood clogging small blood vessels, which can cause confusion, dizziness and stroke-like symptoms. This is not a common treatment but the procedure may be recommended if the level of the abnormal protein made by the plasma cells is dangerously high.
• Clinical trials – aim to explore new and improved treatments for multiple myeloma. Ask your doctor what trials are available and if you may be eligible.

You may also have other types of treatment to help control your symptoms, such as:

• Blood transfusions to help with anaemia
• Pain-relieving drugs
• Antibiotics to help control infections
• Antibodies also known as immunoglobulins from blood donors to help prevent infections

When a cure for multiple myeloma isn't possible

If multiple myeloma has been diagnosed in its later stages, the cancer may have spread to the point where disease control is no longer possible. Treatment then focuses on improving quality of life by relieving the symptoms. This is called end of life or palliative care treatment and may include medications to relieve pain, nausea and vomiting.

Where to get help

• Your GP (doctor)
• Cancer Council Victoria, Information and Support Service Tel. 13 11 20
• Multilingual Cancer Information Line, Victoria Tel. 13 14 50
• WeCan website helps people affected by cancer find the information, resources and support services they may need following a diagnosis of cancer.
• Myeloma Foundation of Australia Tel. (03) 9428 7444