By Leon Hwang, M.D.
Not long ago, multiple myeloma—a bone marrow cancer in which blood plasma cells proliferate and destroy bones and vital organs—was a devastating diagnosis. Life expectancy was limited, the standard treatment was difficult and, for most patients, the treatment was not terribly effective.
But as with so many cancers, a plethora of new drugs has been a game changer. Not only are these medications keeping patients alive longer, they are less toxic than earlier therapies and far easier to tolerate. And if one drug stops working, there is usually another to try. And there are many more in the pipeline. Like other oncologists, I now have multiple myeloma patients who are doing fine 10, and even 15, years after diagnosis.
What is Multiple Myeloma?
Like leukemia and lymphoma, multiple myeloma is a blood cancer. It is not exactly rare, but it is uncommon, accounting for about 17% of blood cancers and only 1% to 2% of all cancers.
Blood cells, including red cells, white cells and platelets, develop in the bone marrow. A plasma cell is a kind of white blood cell that produces antibodies to fight infections, and when you are ill, you produce many, many copies of the antibody specific to your infection. As the infection goes away, these antibodies should eventually go away as well. In multiple myeloma, one of your plasma cells continues to uncontrollably make copies of itself.
These out-of-control plasma cells crowd out normal blood cells in your bone marrow, leading to low blood counts. The most common result is anemia, a deficiency in healthy red blood cells that can make you tired and short of breath. But low white blood cell counts can also make patients vulnerable to infection, and a low platelet count can cause unexplained bleeding and bruising. Multiple myeloma causes bone loss and fractures, producing characteristic holes in the bones, most commonly in the spine, pelvis and rib cage.
Other problems that may arise include kidney damage, high calcium in your blood (which can lead to stroke or heart attack), and numbness or weakness in your extremities (known as peripheral neuropathy).
Who is at Risk?
Age is the biggest risk factor for multiple myeloma. Fewer than 1% of cases are diagnosed in people younger than 35, and more than half of cases are among people 65 or older. African Americans are more than twice as likely to get multiple myeloma as whites, and the disease is slightly more common in men. You may be slightly more at risk if you’ve had family members with multiple myeloma. Being overweight is also a risk factor, and multiple myeloma is associated with exposure to Agent Orange and other chemicals, including benzene.
Symptoms and Diagnosis
It is tricky to diagnose multiple myeloma because the symptoms, especially anemia, can apply to many conditions.
Symptoms may include fatigue, shortness of breath and dizziness, as well as bone pain or bones that easily break. Other symptoms are wide-ranging, including nausea and/or constipation, loss of appetite, mental fogginess or confusion, frequent infections, weight loss, weakness or numbness in your legs and excessive thirst and/or urination.
Because multiple myeloma is uncommon and we don’t screen for it the way we do breast and colon cancers, doctors often miss it the first time around. If you have persistent and unexplained anemia, bone pain, kidney problems or other serious symptoms, and your doctor did not get to the bottom of your problem during the first go-round, don’t give up.
A full workup for multiple myeloma involves an extensive array of blood and urine tests, including a serum protein electrophoresis, which looks for a specific protein that is made by the antibodies produced by the abnormal plasma cells. Your doctor may also do imaging studies of your bones and other organs, and a bone marrow biopsy to determine if there are myeloma cells in the marrow and, if so, how many. If you are diagnosed with this bone marrow cancer, your oncologist will probably do further chromosome analyses, which can help determine recommendations for treatment and prognosis.
Treatment for Multiple Myeloma
The standard first-line treatment is a combination of chemotherapy drugs. Once patients goes into remission, they will get a bone marrow transplant, also called a stem cell transplant, if they are healthy and strong enough. This is often followed by two years of maintenance chemotherapy in pill form. But because this disease is mostly seen in older patients, many patients cannot have a bone marrow transplant and instead receive a lighter dose of maintenance chemotherapy. This can be done in pill form as well as intravenously. Since the advent of COVID-19, we have been using more all-pill therapies and are finding them just as effective.
The drugs now are so good that even our patients on maintenance regimens seem to be doing nearly as well as the patients who get the bone marrow transplant, though we don’t yet have the large clinical trials we need to prove that definitively.
With multiple myeloma, having a positive attitude really helps because this is not a sprint; it’s a marathon. The treatments are so much better than they used to be, but you need to see your oncologist regularly, keep up with your vaccinations, exercise, eat well and protect yourself from infection, particularly COVID-19, because patients with blood cancers have suppressed immune systems and are at especially high risk of becoming severely ill.
The good news is there are even better drugs in the pipeline, so patients are riding a wave of increasingly effective therapies. For multiple myeloma patients and their oncologists, it is a very hopeful and exciting time.
Leon Hwang, M.D., is a board-certified oncologist and clinical researcher who serves as chief of oncology for Mid-Atlantic Permanente Medicine’s Washington, DC and southern Maryland area. He sees patients at Kaiser Permanente Gaithersburg, Capitol Hill and Largo medical centers.
For more on health and wellness, subscribe to our weekly Health newsletter.