Multiple Myeloma: Diagnosis and Treatment

 

Multiple myeloma accounts for 1.6% of all cancer cases and approximately 10% of hematologic malignancies in the United States. In 2015, an estimated 28,850 new cases of multiple myeloma were diagnosed in the United States, and the disease caused more than 11,000 deaths. Patients older than 65 years account for 85% of those diagnosed with multiple myeloma, and there is a twofold increased incidence in blacks compared with whites. Patients may present with bone pain or with symptoms that are often nonspecific, such as nausea, vomiting, malaise, weakness, recurrent infections, and weight loss. Many patients present with only laboratory abnormalities, such as anemia, renal disease, and elevated protein levels. The diagnosis of multiple myeloma requires increased numbers of immature, abnormal, or atypical plasma cells in the bone marrow; a monoclonal protein in the serum or urine; or characteristic bone lesions. The diagnostic workup in a patient with suspected multiple myeloma should include a complete blood count with differential; serum chemistries; creatinine, lactate dehydrogenase, and beta2-microglobulin tests; immunoglobulin studies; skeletal survey; and bone marrow evaluation. Initiation of chemotherapy and assessment of eligibility for autologous stem cell transplantation require referral to an oncologist. Most patients with multiple myeloma will receive thromboprophylaxis, bisphosphonate therapy, and prophylaxis against infection at some point in their treatment. Family physicians play a role in assessing these patients for infection, adverse treatment effects, and renal and thrombotic complications, and in managing issues related to pain, nutrition, and psychosocial support.

Multiple myeloma is a malignancy of plasma cells; these cells accumulate in bone marrow and overproduce a monoclonal protein. Plasma cell malignancies include a spectrum of diseases, from monoclonal gammopathy of undetermined significance (MGUS) to smoldering multiple myeloma (SMM), clinical multiple myeloma, and, rarely, plasma cell leukemia. The disease process is insidious, with end-organ damage occurring over years.1,2

WHAT IS NEW ON THIS TOPIC: MULTIPLE MYELOMA

In 2014, the International Myeloma Working Group revised the diagnostic criteria for multiple myeloma. These new criteria add myeloma-defining events, the presence of any one of which is sufficient to diagnose multiple myeloma.

Intravenous zoledronic acid (Reclast) or pamidronate is recommended for all patients with multiple myeloma who are receiving treatment, regardless of the presence of bone lesions.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The diagnostic workup for suspected multiple myeloma should include a complete blood count with differential; serum chemistries; measurement of creatinine, lactate dehydrogenase, and beta2-microglobulin levels; immunoglobulin studies; a skeletal survey; and bone marrow evaluation.

C

1012

Patients with multiple myeloma should be evaluated by an oncologist to determine if they are a candidate for autologous stem cell transplantation; this should include assessing comorbid conditions and functional status, which may be defined upon referral.

C

2, 6, 15, 16

Patients with multiple myeloma should receive bisphosphonate therapy (i.e., zoledronic acid [Reclast] or pamidronate) when first diagnosed.

A

37, 38

Patients with multiple myeloma should receive thromboprophylaxis when first diagnosed.

C

41, 42


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The diagnostic workup for suspected multiple myeloma should include a complete blood count with differential; serum chemistries; measurement of creatinine, lactate dehydrogenase, and beta2-microglobulin levels; immunoglobulin studies; a skeletal survey; and bone marrow evaluation.

C

1012

Patients with multiple myeloma should be evaluated by an oncologist to determine if they are a candidate for autologous stem cell transplantation; this should include assessing comorbid conditions and functional status, which may be defined upon referral.

C

2, 6, 15, 16

Patients with multiple myeloma should receive bisphosphonate therapy (i.e., zoledronic acid [Reclast] or pamidronate) when first diagnosed.

A

37, 38

Patients with multiple myeloma should receive thromboprophylaxis when first diagnosed.

C

41, 42


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence

The Authors

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THOMAS C. MICHELS, MD, MPH, is a residency faculty physician at Madigan Army Medical Center Family Medicine Residency, Tacoma, Wash....

KEITH E. PETERSEN, DO, is a residency faculty physician at Madigan Army Medical Center Family Medicine Residency.

Address correspondence to Thomas C. Michels, MD, MPH, P.O. Box 33425, Joint Base Lewis-McChord, WA 98433 (e-mail: Thomas.c.michels.civ@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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