1. Consider myeloma in bone pain, infection or anaemia.
Consider myeloma in patients with persistent bone pain – such as non-improving back or rib pain, or osteoporosis – recurrent or persistent infection, renal impairment or unexplained anaemia. The majority of new cases tend to occur in those over 60 years of age, although 10-15% of cases develop in those aged under 45. Myeloma is a common haematological cancer. Early diagnosis is important as myeloma can have debilitating complications that affect the bones, kidneys and immune system, causing a dramatic impact on quality of life.
2. Test both urine and serum.
Myeloma is characterised by the secretion of a monoclonal immunoglobin (paraprotein), which is detectable by serum protein electrophoresis in most cases. But 20% of patients produce Bence Jones protein or free light chains in the absence of paraprotein. These are excreted and readily detected in urine. Send a urine sample to the laboratory, as dipstick testing for protein is unreliable for Bence Jones protein.
3. Be aware of monoclonal gammopathy of undetermined significance.
Monoclonal gammopathy of undetermined significance (MGUS) may be identified in 1-3% of the population over 65 and does not need urgent referral. However, a small proportion of patients may develop myeloma, so patients with MGUS should be monitored every three to six months by their haematologist. Patients with MGUS have paraprotein in the serum, but no other clinical features of myeloma.
4. Avoid NSAIDs.
Active pain management is important, as bone complications can severely affect quality of life. Use non-opioids or opioids, but avoid NSAIDs as they can exacerbate existing renal damage caused by cast nephropathy.
5. Promote patient mobility.
Keeping mobile and maintaining a level of physical activity minimises muscle weakness, helps protect bones and improves overall health. Physiotherapy can be helpful. Contact Macmillan nurses and local services for additional support.
6. Encourage fluid intake to help prevent kidney damage.
Renal impairment is found in up to 20% of patients at diagnosis. Encourage patients to drink at least 3l of fluid a day and avoid nephrotoxic drugs. Hypercalcaemia requires urgent admission.
7. Treat infection aggressively.
Myeloma patients are immunosuppressed. Minor infections should be treated with oral antibiotics and patients should receive flu and pneumonia vaccination.
8. Be vigilant for psychological problems.
Depression and anxiety can be common in both patients and their families. This should be actively managed and monitored.
9. Remember thromboembolism.
Like many cancer patients, myeloma patients are at risk of venous thromboembolism (VTE) and treatments increase this risk. If patients develop a swollen leg, pleuritic chest pain, haemoptysis or sudden breathlessness, VTE should be suspected.
10. Be aware of the side-effects of bisphosphonates.
Myeloma patients benefit from long-term bisphosphonate therapy. A rare side-effect is osteonecrosis of the jaw, so patients need to maintain good dental hygiene at all times.
Professor Graham Jackson is a consultant haematologist at Newcastle Hospitals trust and professor of clinical haematology at Newcastle University
Myeloma UK offers a range of educational resources for healthcare professionals. To assist GPs in the diagnosis of myeloma, Myeloma UK has developed the Myeloma Diagnosis Pathway, which outlines to GPs the signs and symptoms of myeloma and the investigations to carry out if myeloma is suspected. Download it at myeloma.org.uk/diagnosis-pathway