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?
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)