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Cancer of the blood & bone marrow now more treatable

18 March 2013 / by / no comments

Cancer of the blood & bone marrow now more treatable

Mul­ti­ple myeloma has become more a chronic dis­ease than a ter­mi­nal one, thanks to new treat­ments.

BY: Eleanor Yap

Ten years ago, those with mul­ti­ple myeloma (MM) (also known as myeloma or plasma cell myeloma), a can­cer of the bone mar­row plasma cells (plasma cells make anti­bod­ies called immunoglob­u­lin which help fight off infec­tions), were only liv­ing three to four years or less and were dying painful deaths. How­ever, today, this can­cer no longer is cat­e­gorised as a ter­mi­nal dis­ease but a chronic one like dia­betes, and those with MM, can expect to live up to 10 years, thanks to new treatments.

Age­lesson­line finds out more from Dr Daryl Tan, spe­cial­ist in haema­tol­ogy for more than 10 years, and a con­sul­tant at Raf­fles Can­cer Cen­tre, about this dis­ease and what we should watch out for:

How many cases are there in Sin­ga­pore each year? How old is your old­est patient?

It affects 100 to 120 new patients in Sin­ga­pore each year. This is a small amount com­pared to other can­cers but we are see­ing it increas­ing, espe­cially with an age­ing pop­u­la­tion in Sin­ga­pore. My old­est patient was 92-​year-​old.

Do you feel the fig­ure of 100 patients a year could be a higher as it could be misdiagnosed?

One hun­dred to 120 will be the min­i­mal fig­ure. This is based on the num­bers we gath­ered from the restruc­tured hos­pi­tals. If we include private-​sector patients as well, the num­ber will be higher. There may also be patients who are asymp­to­matic and may not present to the doc­tor. For symp­to­matic patients, as the symp­toms are non-​specific, diag­no­sis may also be missed or delayed if the treat­ing physi­cians do not think of myeloma and do not per­form the screen­ing test for myeloma.

Why are peo­ple not aware of this cancer?

Most peo­ple who develop MM have no clearly iden­ti­fi­able risk fac­tors for the dis­ease, how­ever, I under­stand men over 50 years and those who are obese are predisposed.

Can you explain this cor­re­la­tion? Is age­ing also a risk factor?

Age­ing is a risk for most can­cers. This is a result of cumu­la­tive acquire­ment of genetic abnor­mal­i­ties or muta­tions. We still do not exactly know why it afflicts men and more obese indi­vid­u­als. This is just an obser­va­tion based on epi­demi­o­log­i­cal stud­ies. Nonethe­less, I need to high­light that being young or lean is also no pro­tec­tion against myeloma. I’ve seen patients as young as 22-​years-​old and most of my patients are in fact not obese.

What are some of the com­mon symp­toms of MM?

MM patients may expe­ri­ence symp­toms requir­ing med­ical atten­tion. How­ever, some patients may not even have any symp­toms or their symp­toms may be vague. Com­mon signs and symp­toms of MM include bone pain, bro­ken bones, nau­sea, vom­it­ing, weak­ness and tired­ness, fre­quent infec­tions, ner­vous sys­tem prob­lems, anaemia and hyper­cal­cemia (a con­di­tion of too much cal­cium in the blood caus­ing con­sti­pa­tion, fre­quent thirst and uri­na­tion, mus­cle aches, and kid­ney problems).

So how can MM be diagnosed?

It is as sim­ple as a rou­tine blood test. If a patient has it, we will need to find out the stage of myeloma he or she has. The stages start from MGUS (Mon­o­clonal Gam­mopa­thy of Unknown Sig­nif­i­cance) to smol­der­ing myeloma to MM. Early detec­tion is good before more com­pli­ca­tions can arise if left untreated. These can include kid­ney fail­ure and bone fracture.

What are the treatments?

Treat­ment is meant to stop the tumour from grow­ing and keep­ing the dis­ease from spread­ing to other organs in the body. If the patient is deemed fit, we would rec­om­mend stem-​cell trans­plan­ta­tion. This involves using high-​dose chemother­apy along with a trans­fu­sion of pre­vi­ously col­lected imma­ture blood cells (stem-​cells) to replace dis­eased or dam­aged mar­row. Oth­er­wise, it would be tar­geted chemother­apy such as Borte­zomib and Lenalido­mide to kill the myeloma cells, with sup­port­ing med­i­cines such as aspirin; cor­ti­cos­teroids; or radi­a­tion ther­apy, which uses high-​energy pen­e­trat­ing waves to dam­age myeloma cells and stop their growth.

Com­mon side effects from treat­ment include tired­ness and gain­ing weight, wors­en­ing of dia­betes, high blood pres­sure, can affect nerves of feet and hands, infec­tions, con­sti­pa­tion, kid­ney com­pli­ca­tions and blood clots. We will need to mon­i­tor the treat­ment reg­u­larly and look at qual­ity of life of the patient to as near nor­mal as before, as well as reduced tox­i­c­ity in pre­scrib­ing the treat­ment. One of the things you will need to avoid when tak­ing the drugs is green tea and vit­a­min C, which could coun­ter­act the medicines.

How much can the med­i­cines cost?

Med­i­cines alone can aver­age S$6,000 to $10,000 a month.

What about the cost of stem-​cell trans­plants if a patient requires one?

[cap­tion id=“attachment_3174” align=“alignright” width=“272” caption=“Skull of a myeloma patient.”][/​caption]

The aver­age cost is between S$80,000 to S$100,000. It can also be heav­ily sub­sidised if the patient is a Sin­ga­pore cit­i­zen in a restruc­tured hos­pi­tal. How­ever, only younger patients (less than 65 years as a guide) are eli­gi­ble due to the tox­i­c­i­ties involved with stem-​cell transplant.

What about alter­na­tive therapies?

If the drugs pre­scribed are effec­tive, there is really no need for alter­na­tive ther­a­pies. How­ever, if they have side effects, alter­na­tive ther­a­pies may come in use­ful like acupunc­ture to treat numb­ness of the hands. There is a study going on in Sin­ga­pore Gen­eral Hos­pi­tal (SGH) on this.

So if some­one has MM, how do they con­tinue to live a qual­ity life?

They cer­tain can. We empha­sise on reliev­ing the symp­toms first. With effec­tive treat­ments nowa­days, the symp­toms resolve rapidly with treat­ment of myeloma. We pro­vide ancil­lary med­i­cines too to strengthen the bones and boost the blood counts, so that patients can recover more rapidly and get on with their daily routines.

You are a part of the MM Asia Net­work, which will help with national data and allow for clin­i­cal tri­als on MM. (In Sin­ga­pore, the doc­tors are from SGH, Raf­fles Hos­pi­tal and the National Uni­ver­sity Hos­pi­tal, while other doc­tors in the Net­work come from Japan, South Korea, Thai­land, Hong Kong, China and Tai­wan.) What will be first area of busi­ness on the agenda?

To iden­tify if there is a unique sig­na­ture of the ‘Asian myeloma’. Most of the infor­ma­tion in the lit­er­a­ture to date is based on West­ern stud­ies. We will next try to iden­tify if there are areas in the man­age­ment of myeloma where we can have eas­ier access to good drugs and imple­ment clin­i­cal tri­als. This will help improve the over­all out­comes of Asian patients with myeloma.

When will we see more con­crete local data?

We already have pre­lim­i­nary data on the clin­i­cal char­ac­ter­is­tics of the ‘Asian myeloma’. This has been pre­sented at the Amer­i­can Soci­ety of Clin­i­cal Oncol­ogy annual meet­ing last year. Next steps will be look­ing at enrolling Asian myeloma patients in clin­i­cal tri­als and per­haps have some com­mon pro­to­cols among Asian physi­cians. These may take some time to evolve.

Is there a sup­port group for MM patients?

Yes. It was started in 2009 in SGH. In 2010, the first national myeloma sup­port group was formed. We have been hav­ing yearly meet­ings. It is impor­tant for myeloma patients to know that they are not alone. As patients with myeloma are sur­viv­ing longer and longer with new effect treat­ments, the preva­lence of at any point of time is indeed increas­ing now. It is no longer an orphan dis­ease that we used to think of where patients only sur­vive three to four years due to the lack of effec­tive ther­a­pies. Due to its rar­ity, many patients suf­fered in silence. It is a dif­fer­ent pic­ture alto­gether now.

(** PHOTO CREDIT: Old wise man, beta­cam, stock.xchng; myeloma patient’s skull, Dr Daryl Tan, Raf­fles Can­cer Centre)


Multiple myeloma has become more a chronic disease than a terminal one, thanks to new treatments.

 

BY: Eleanor Yap

 

Ten years ago, those with multiple myeloma (MM) (also known as myeloma or plasma cell myeloma), a cancer of the bone marrow plasma cells (plasma cells make antibodies called immunoglobulin which help fight off infections), were only living three to four years or less and were dying painful deaths. However, today, this cancer no longer is categorised as a terminal disease but a chronic one like diabetes, and those with MM, can expect to live up to 10 years, thanks to new treatments.

Agelessonline finds out more from Dr Daryl Tan, specialist in haematology for more than 10 years, and a consultant at Raffles Cancer Centre, about this disease and what we should watch out for:

 

How many cases are there in Singapore each year? How old is your oldest patient?

It affects 100 to 120 new patients in Singapore each year. This is a small amount compared to other cancers but we are seeing it increasing, especially with an ageing population in Singapore. My oldest patient was 92-year-old.

 

Do you feel the figure of 100 patients a year could be a higher as it could be misdiagnosed?

One hundred to 120 will be the minimal figure. This is based on the numbers we gathered from the restructured hospitals. If we include private-sector patients as well, the number will be higher. There may also be patients who are asymptomatic and may not present to the doctor. For symptomatic patients, as the symptoms are non-specific, diagnosis may also be missed or delayed if the treating physicians do not think of myeloma and do not perform the screening test for myeloma.

 

Why are people not aware of this cancer?

Most people who develop MM have no clearly identifiable risk factors for the disease, however, I understand men over 50 years and those who are obese are predisposed.

 

Can you explain this correlation? Is ageing also a risk factor?

Ageing is a risk for most cancers. This is a result of cumulative acquirement of genetic abnormalities or mutations. We still do not exactly know why it afflicts men and more obese individuals. This is just an observation based on epidemiological studies. Nonetheless, I need to highlight that being young or lean is also no protection against myeloma. I’ve seen patients as young as 22-years-old and most of my patients are in fact not obese.

 

What are some of the common symptoms of MM?

MM patients may experience symptoms requiring medical attention. However, some patients may not even have any symptoms or their symptoms may be vague. Common signs and symptoms of MM include bone pain, broken bones, nausea, vomiting, weakness and tiredness, frequent infections, nervous system problems, anaemia and hypercalcemia (a condition of too much calcium in the blood causing constipation, frequent thirst and urination, muscle aches, and kidney problems).

 

So how can MM be diagnosed?

It is as simple as a routine blood test. If a patient has it, we will need to find out the stage of myeloma he or she has. The stages start from MGUS (Monoclonal Gammopathy of Unknown Significance) to smoldering myeloma to MM. Early detection is good before more complications can arise if left untreated. These can include kidney failure and bone fracture.

 

What are the treatments?

Treatment is meant to stop the tumour from growing and keeping the disease from spreading to other organs in the body. If the patient is deemed fit, we would recommend stem-cell transplantation. This involves using high-dose chemotherapy along with a transfusion of previously collected immature blood cells (stem-cells) to replace diseased or damaged marrow. Otherwise, it would be targeted chemotherapy such as Bortezomib and Lenalidomide to kill the myeloma cells, with supporting medicines such as aspirin; corticosteroids; or radiation therapy, which uses high-energy penetrating waves to damage myeloma cells and stop their growth.

Common side effects from treatment include tiredness and gaining weight, worsening of diabetes, high blood pressure, can affect nerves of feet and hands, infections, constipation, kidney complications and blood clots. We will need to monitor the treatment regularly and look at quality of life of the patient to as near normal as before, as well as reduced toxicity in prescribing the treatment. One of the things you will need to avoid when taking the drugs is green tea and vitamin C, which could counteract the medicines.

 

How much can the medicines cost?

Medicines alone can average S$6,000 to $10,000 a month.

 

What about the cost of stem-cell transplants if a patient requires one?

Skull of a myeloma patient.

The average cost is between S$80,000 to S$100,000. It can also be heavily subsidised if the patient is a Singapore citizen in a restructured hospital. However, only younger patients (less than 65 years as a guide) are eligible due to the toxicities involved with stem-cell transplant.

 

What about alternative therapies?

If the drugs prescribed are effective, there is really no need for alternative therapies. However, if they have side effects, alternative therapies may come in useful like acupuncture to treat numbness of the hands. There is a study going on in Singapore General Hospital (SGH) on this.

 

So if someone has MM, how do they continue to live a quality life?

They certain can. We emphasise on relieving the symptoms first. With effective treatments nowadays, the symptoms resolve rapidly with treatment of myeloma. We provide ancillary medicines too to strengthen the bones and boost the blood counts, so that patients can recover more rapidly and get on with their daily routines.

 

You are a part of the MM Asia Network, which will help with national data and allow for clinical trials on MM. (In Singapore, the doctors are from SGH, Raffles Hospital and the National University Hospital, while other doctors in the Network come from Japan, South Korea, Thailand, Hong Kong, China and Taiwan.) What will be first area of business on the agenda?

To identify if there is a unique signature of the ‘Asian myeloma’. Most of the information in the literature to date is based on Western studies. We will next try to identify if there are areas in the management of myeloma where we can have easier access to good drugs and implement clinical trials. This will help improve the overall outcomes of Asian patients with myeloma.

 

When will we see more concrete local data?

We already have preliminary data on the clinical characteristics of the ‘Asian myeloma’. This has been presented at the American Society of Clinical Oncology annual meeting last year. Next steps will be looking at enrolling Asian myeloma patients in clinical trials and perhaps have some common protocols among Asian physicians. These may take some time to evolve.

 

Is there a support group for MM patients?

Yes. It was started in 2009 in SGH. In 2010, the first national myeloma support group was formed. We have been having yearly meetings. It is important for myeloma patients to know that they are not alone. As patients with myeloma are surviving longer and longer with new effect treatments, the prevalence of at any point of time is indeed increasing now. It is no longer an orphan disease that we used to think of where patients only survive three to four years due to the lack of effective therapies. Due to its rarity, many patients suffered in silence. It is a different picture altogether now.

 

(** PHOTO CREDIT: Old wise man, betacam, stock.xchng; myeloma patient’s skull, Dr Daryl Tan, Raffles Cancer Centre)


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