Multiple Myeloma 101: An Incurable But ‘Very Treatable’ Disease

While a diagnosis of multiple myeloma can be overwhelming for patients, the disease is very treatable, according to Dr. Andrew Yee.

At CURE®’s Educated Patient® Summit on Multiple Myeloma, Yee, an assistant professor of medicine at Massachusetts General Hospital Cancer Center in Boston, discussed the signs and symptoms of the disease, how it’s staged, and explored the different treatment phases a patient might go through over the course of their journey.

In 2021, Yee explained, approximately 35,000 new cases of multiple myeloma are expected to be diagnosed. While not as common as lung cancer or colon cancer, it is the second most common blood-related cancer, with 0.8% of the population having a lifetime risk of developing multiple myeloma. To put that into perspective, Yee noted, the average lifetime risk of developing breast cancer is around 12%, with lung cancer at 6%.

As with most malignancies, multiple myeloma is a disease that affects the older patient population, with the median age at diagnosis of 69 years old. And while its cause is unknown, Yee noted, chronic inflammation from infection and environmental exposures may play a role, and as such, there is no defined role for screening for multiple myeloma as there is for other malignancies. “It's not like colon cancer, (for which) you have colonoscopies, or for breast cancer, there's mammography,” Yee said.

There is also a small hereditary component to the disease, according to Yee, though it is not often cause for concern. While there is no specific genetic test to screen for, the risk to family members is about twice that of baseline, but still relatively low. Yee highlighted the work being done by his colleagues at Dana Farber Cancer Center on the PROMISE study, which is examining the hereditary genetic components of multiple myeloma.

When it comes to the signs of the disease, Yee reviewed the results of 1,027 patients who had been diagnosed and summed up the symptoms they presented with. Bone pain was present in 59% of patients, and fatigue was present in 32%. Twenty four percent of patients experienced weight loss, with 50% losing roughly 20 pounds or more. About 73% of patients presented with anemia, and almost 80% of patients had some abnormal skeletal findings on an X-ray, such as bone lesions (66%) or osteoporosis (23%).

“What can be challenging in multiple myeloma is that the majority of patients, when they present, they have symptoms that are very common for people in general,” Yee said. “A lot of times, patients can have these symptoms for months before the diagnosis, which is very common.”

While identifying myeloma can seem challenging, Yee said, doctors will often rely on more sensitive imaging tests such as CT scans or MRI or PET scans. He went on to note one example of a patient who had “clean” spinal X-rays but was later found to have lytic lesions, or softened sections of bone, in two vertebrae when a more in-depth CT scan was done. “This illustrates that when we see patients with multiple myeloma or concern for multiple myeloma, generally speaking, we do more sensitive imaging such as CT scan or MRI to fully evaluate the patient,” Yee explained.

Different staging

Unlike cancers that involve solid tumors, multiple myeloma is staged in a completely different way, according to Yee, and focuses on lab tests and blood work. “The ISS (International Staging System) staging, which was developed in 2005, looks at beta-2 microglobulin and albumin to divide patients into three different stages,” Yee said. “And more recently, in 2015, we've incorporated LDH (lactate dehydrogenase) and FISH (fluorescence in situ hybridization), which are the cytogenetic abnormalities that are in part of the myeloma cell.”

To obtain FISH information, a bone marrow biopsy will usually be done to a lesion to examine the cytogenetic – or chromosomal – abnormalities that are present in a patient’s genes. This information can then be used to stratify patients into different risk categories, which in turn will also often influence treatment decisions.

While myeloma is not considered curable, Yee noted, it is very treatable, with the main goals of treatment being to improve the patient’s quality of life by improving symptom burden, and ultimately extending a patient’s life. “A fair number of patients we see, they don't feel well because of the disease related to a bone lesion or they're tired,” Yee said. “So the number one goal is to help patients feel better, and then also to help not only to help patients feel better, but also to live longer.”

Treatment is effective and tolerable

Yee also highlighted that while it is a disease usually found in an older population, treatments are generally effective and tolerable.

Myeloma treatment can be divided into several phases, Yee explained. At first, when a patient has a myeloma-defining event, such as a bone lesion or kidney dysfunction, initial therapy for the first several months to a year involves a fair number of visits for treatment – often weekly – to improve the disease burden and to get any symptoms under better control. This is also a point when other therapies such as autologous stem cell transplant, which involves high dose chemotherapy, could be brought up.

Once the initial course of therapy has been completed, according to Yee, the majority of patients have a great response and often feel better enough to move onto what is called maintenance therapy, where the amount of therapy is streamlined down to one or two drugs to maintain that response for as long as possible.

However, Yee noted, over time, some patients can relapse, and the disease will return. At that point, more treatment is discussed, with an emphasis on supportive care to ensure that patients are handling treatment well. “How can we make sure that, because this is for the long haul, … patients have as good an experience as possible throughout this course,” Yee explained.

Role of clinical trials

This is also the point where it could be worth considering participating in a clinical trial. “It's through clinical trials that we identify better and better treatments and learn how we optimize the care for multiple myeloma,” he said.

The essential thing with myeloma treatment, Yee noted, is constant communication between patient and provider. “As patients are on treatment, we have ways to make sure that not only you feel that you're tolerating it well, but we also want to make sure that you're also responding to the treatment,” he said. Ultimately, while a new diagnosis of multiple myeloma can be daunting, Yee finished his presentation by reiterating that it is a “very treatable” disease, and that the majority of patients do very well with treatment.

“For many patients, I say this is like the front burner (issue) for them,” Yee concluded. “But the goal for the majority of patients is to take it from the front burner and just put it in the back burner so that patients can do what they enjoy to do and move on with their life and have as full a life as possible.”

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