Multiple Myeloma

Dr Kingsley’s comments

Although multiple myeloma is one of the blood cancers, it differs somewhat from the leukaemias, so I will describe them separately. Many people do not realise that multiple myeloma is a blood cancer. Nevertheless, they are all the result of something going wrong in the bone marrow, where the blood is formed.

Multiple myeloma is not a common cancer, accounting for about only 1% of all cancers, yet I have seen quite a few. It tends to occur later in life, being rare under the age of 40 years old. There is a considerable range of its effects, the earliest stage being called monoclonal gammopathy. At this stage, certain blood tests have shown a specific abnormality indicating the problem, but the patient is usually not given any treatment, the specialist usually recommending a wait-and-see approach. However, as this stage effectively always develops into full-blown myeloma, I would always suggest doing something to prevent its final conversion.

The full-blown multiple myeloma is known as a ‘plasma cell leukaemia’. Medical textbooks say it is incurable, as with many cancers, but the condition achieved a degree of ‘publicity’ when Professor Michael Gearin-Tosh of Oxford University wrote his book entitled ‘A Medical Maverick’, which was serialised in a major Sunday newspaper. He wrote the book when he had ‘survived’ for eight years, and he remains remarkably well to this day. You can obtain a copy of his book by clicking here. I have a patient who has had multiple myeloma for about 24 years, who is doing remarkably well, despite a number of ups and downs.

There is very little known about the cause of most cancers, but then mainstream medicine prefers to ‘treat’ a condition once it has appeared, and isn’t particularly interested in why it has happened. Nevertheless, multiple myeloma seems to be associated with exposure to radiation, even though I am not aware that my patients have been particularly exposed to it.

In the very early stages, there is usually a general feeling of not being so well, a bit more tired than usual and perhaps a little shortness of breath. Such complaints justify a visit to the doctor, blood tests often showing a straightforward iron deficiency anaemia. On further testing, more specific features suggest early myeloma. Sometimes the earlier stages affect the white blood cells, and therefore the immune system, so that the person seems to pick up every bug going around, what doctors refer to as ‘recurrent infections’.

If the early symptoms and signs do not alert someone to what is going on, and the condition progresses before it is eventually diagnosed as multiple myeloma, quite a number of other features may eventually occur. As the myeloma eventually deposits in bone, bone pain may occur, which may, however, only start as generalised aching in various parts of the body. An X-ray will clinch the diagnosis. In other circumstances, someone may fracture a bone more easily from a fall than would seem reasonable, or a rib from coughing or sneezing. Again, an X-ray will lead to the diagnosis.

The effect of myeloma cells on the body can produce quite a varied set of symptoms and signs. Thirst may be one of them, which can also be a sign of diabetes, a more likely diagnosis of such a symptom. However, if blood tests do not show a raised blood sugar, they may show a raised level of calcium in the blood, as the myeloma deposits in the bones release calcium into the bloodstream.

Oddly enough, the same effect, the loss of calcium from the bones may lead to sciatica because of the loss of structure in the spinal column, especially in the lower (lumbar) area, causing a pinching effect on the nerves leaving the spinal cord there. Also, a person who has had a mild form of multiple myeloma for a long time, without realising the significance of some of the initial symptoms, may complain he or she has become shorter than before.

One of the effects of the changed characteristics of the blood is that it becomes ‘thicker’. This simply means that blood will not flow so well through a number of tissues, and the eyes and kidneys seem to be most often affected. Blindness can occur if the sensitive arteries to the eye clot, and, because the kidneys need a very large flow of blood for them to do their important work of filtering out what the body wants to excrete, they can fail, which is serious when it happens. When the blood becomes viscous, any organ of the body is at risk, so a person can develop diminished consciousness if the blood supply to the brain lowers the amount of oxygen getting to it.

A whole series of blood and urine tests are done to clarify not only the diagnosis, but also to establish the status and extent of the myeloma. While ordinary routine blood tests usually show something out of place, the serum is examined more carefully and more specifically by a process called electrophoresis. This searches for a particular band called paraprotein, which is tested every so often to see if the condition is progressing or is responding to any treatment that has been started. Before this became available, the urine was examined for the presence or absence of Bence Jones protein, which is another classical marker for multiple myeloma. It is still measured in some centres.

A bone marrow biopsy will be done early on, also to establish the diagnosis and to stage the cancer. It will be repeated every so often. A fairly wide-bored needle is inserted into the bone marrow of the hipbone for a sample to be extracted and sent to the laboratory for examination. In addition, a complete scan of the skeleton will be carried out to establish the extent of the deposits in the bones.

There is no place for radiotherapy in the general treatment plan of multiple myeloma, but it is occasionally used for specific areas of damaged bone. To limit the effect on bones, drugs such as Bonefos are being used more and more. They seem able to limit the displacement of calcium from bones by the myeloma deposits. If there is pain, analgesics (pain killers) are prescribed, but they tend to cause constipation, so are best avoided if at all possible.

Chemotherapy is only started when the condition is clearly progressing. This is based upon rising levels of paraproteins in the blood and Bence Jones protein in the urine, if it is being measured. Various regimes of chemotherapy have been evaluated, usually also including steroids, some patients doing really quite well.

Occasionally a form of bone marrow transplant is tried, but the bone marrow is totally destroyed by chemotherapy before the transplant is given, which renders the patient vulnerable to any infection. Patients are therefore barrier nursed to try to keep them free of infection. High doses of antibiotics are given all the time, intravenously and orally for the same reasons.

Occasionally the patient dies during the process, but if they do not, they usually feel absolutely dreadful. Some of my patients who have been through it told me they wanted to die at some stage in the process, yet they survived. Various other forms of bone marrow reconstitution are sometimes tried, and, more recently, Interferon-alpha has been achieving a degree of success.

An Explanation by Dr Kingsley Before Your Consultation

about your Multiple Myeloma

Most consultations with doctors are fairly quick affairs, lasting perhaps five minutes, even if you are suspected of having multiple myeloma.  You may be lucky to have more time spent on you, but when you have your consultation with me, I will spend as much time as you want.  There is no time limit.  We will take as long as you want.

Often when I see some people for the first time, they are in a state of panic.  They haven’t a clue what it is all about.  No one has explained anything to them.  Perhaps in the past they have been admitted for an emergency operation, or they had simply been told to come into hospital on such-and-such a day when they were either operated on or started a course of chemotherapy or radiotherapy. 

Once in hospital some sort of explanation may have been given, and they were probably seen by a junior doctor who not only took a short history of any symptoms they had, but also examined them to look for any signs of multiple myeloma, but, by then, they were already captive and didn’t really have much choice in the matter.

To be fair to doctors, they assume that their advice is the best on offer.  After all, they are the experts.  Virtually all doctors would treat the condition in roughly the same way, so it seldom occurs to them that you just might not want to follow their advice. 

In any case, most patients have been frightened by their diagnosis and want to get on with the treatment, assuming that the doctor can deal with it for them.  Most people put their faith in their doctor, assuming he knows what he is doing.

There is absolutely no intention on my part to tell you whether to follow your doctor’s advice of not.  That is a decision you have to make.  No one can make it for you, but I will help you make up your mind.

The Consultation

The virtual consultation with me has been planned as though you are with me in my consulting room.  I will go though your history, or the history that I come across so often, explaining the parts of it that give me clues to the cause of people’s problems. 

The chances are that, having taken a medical history from many thousands of patients over nearly forty years of medical practice, especially in the detail that I find so valuable, it is likely that much of it will be appropriate to you.

The consultation is one of the longest parts of this programme, as you would imagine, and it is full of fascinating information.  Periodically I lecture to medical colleagues on the subject of ‘What a clinical history and the clinical examination can tell me’. 

All this information is the result of my many years of listening to patients, letting them tell their stories, believing in their observations that have often been ignored, and learning by experience. 

So, enjoy yourself, feel enlightened, smile, be happy and radiate confidence in what you are going to do.  Be positive and forget the doom and gloom merchants.  If someone has given you a poor prognosis, forget it.  You no longer fit into their statistics.  You are going to do something for yourself.  You are now in charge.

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