Myeloma is a type of cancer affecting plasma cells that occur in the bone marrow. Bone marrow is a soft and spongy type substance found in larger bones. Bone marrow produces three varieties of blood cells; they are red and white blood cells and platelets. Plasma cells are another type of white blood cell in bone marrow. Plasma cells make antibodies
(immunoglobulins) to prevent and fight infection and build up immunity to disease. When a person develops myeloma, plasma cells become malignant (cancerous) and become known as myeloma cells. Myeloma cells produce abnormal antibodies called paraproteins.
Paraproteins do not fight infection adequately and actually reduce the production of normal antibodies. Myeloma cells do not allow a sufficient quantity of normal plasma cells to be produced in bone marrow.
Multiple myeloma is the term used to describe myeloma cells spreading from bone marrow to the rest of the bone (hard part of bone) and damaging bone tissue. Many bones become affected hence myeloma is referred as multiple myeloma. Over 200 Irish people are diagnosed annually with myeloma.
Paraproteins show up in blood and urine tests and myeloma may show up in routine blood tests before symptoms even occur. If myeloma is undiagnosed and is allowed develop it can affect bones, blood and kidneys leading to symptoms. Bone symptoms of myeloma include bone pain (particularly backache), bone fractures, brittle bones (osteoporosis), spinal cord compression (an emergency situation), numbness and pins and needles. Blood problems caused by myeloma include fatigue, infections, anaemia (low red blood cells) and bruising.
Kidneys problems caused by kidney problems include hypercalcaemia (high calcium levels in blood due to destruction of bone cells), dehydration and thicker blood (caused by paraproteins) which further reduces kidney function leading to further kidney problems.
There is currently no programme to screen for myeloma in Ireland or any other country so regular health checks are the only way to reduce risk from myeloma and other cancers.
Blood tests can help diagnose myeloma. Blood counts indicate calcium levels and levels of normal proteins and paraproteins. Blood tests determine kidney function which is another indicator of myeloma. Urine tests check if normal proteins and paraproteins are present. If initial tests indicate that a person may have myeloma, further tests will then be done to confirm diagnosis and determine the extent of the condition. This includes checking immunoglobulin levels (antibodies for fighting infection). Protein electrophoresis of blood and urine indicates the type of paraprotein. Another test is the serum free light chain test which determines if certain minute amounts of abnormal proteins are present (eg) Beta-2 microglobulin.
An X-ray indicates if myeloma cells are damaging bones. A bone marrow biopsy is when a bone marrow sample is taken from the hipbone to determine if myeloma cells are present.
Other tests that help confirm myeloma diagnosis include an MRI scan, a CT scan and an ultrasound.

Treatment choices depend on age, general health, severity of myeloma and patient preferences. Myeloma is currently an incurable disease that is chronic, relapsing and remitting. Treatment aims to control the condition, prolong survival and maximise quality of life. Treatment, if started in time allows bone marrow to recover and stop producing abnormal plasma cells. This is known as remission and a person can have many years of no symptoms.
Relapse (myeloma re-occurs) is a possibility; the reality is that most patients undergo numerous remissions and relapses. A number of different treatment options are available including

Active monitoring

Chemotherapy

Biological therapy

High-dose therapy and stem cell transplant

Maintenance therapy

Treatment of symptoms

Treatment of relapsed myeloma

Pain control
Active Monitoring
When first diagnosed with myeloma, there may be little or no symptoms so doctors may initially decide against treatment and simply monitor the myeloma until it develops further; this is because there is no real benefit in treating myeloma when in the early stages.
Treatment will then start as soon as there is signs of organ damage (eg) kidney damage, bone damage.
Chemotherapy
These are drugs that kill the abnormal proteins that cause myeloma. Chemotherapy is generally central to the treatment for myeloma. Examples of drugs used include cyclophosphamide, vincristine, melphalan, and adriamycin. The symptoms of chemotherapy can be severe as chemotherapy drugs not only kill the abnormal cells; they also kill the body’s normal cells.
Steroids are also given with chemotherapy prevent side-effects such as nausea, vomiting, weight loss and fatigue. Steroids may help promote a feeling of wellbeing. Steroids commonly prescribed with chemotherapy drugs include dexamethasone and prednisolone
(usually in tablet form). Side-effects from steroids include weight gain, stomach irritation, brittle bones and high blood sugar levels.
Biological therapies
Work by stimulating t he body´s own immune system to beat cancer. Drugs commonly used for myeloma include velcade (bortezomib), lenalidomide and thalidomide.
High-dose therapy with stem cell transplant
High-dose therapy and stem cell transplant can accelerate treatment response and increase remission times. Stem cell transplants mean higher doses of chemotherapy can be given as stem cell replacement therapy replaces red and white blood cells and platelets (which

chemotherapy damages). If cells are removed from the person getting treatment it referred to as autologous transplant and if removed from a donor it referred to as allogeneic transplant. Stem cells can be taken from bone marrow or blood.
Maintenance therapy
Maintenance treatment includes chemotherapy or transplant and helps prevent or slow the re-occurrence of the myeloma. Drugs used for maintenance therapy include biological therapies and steroids.
Symptom treatment
Bone symptoms can include bone pain (painkillers can be used) and brittle bones (can be treated with drugs that strengthen bones like bisphosphonates or monoclonal antibodies).
Blood related symptoms include fatigue, anaemia, bruising or infections. Treatment for blood related symptoms can include blood and/or platelet transfusions, erythropoietin, plasmapheresis (if thinning the blood is needed), antibiotics (if infection becomes an issue due to poor immune system), and growth factors (to increase white blood cells).
Kidney related issues include loss of kidney function and hypercalcaemia (high calcium levels). If kidney problems become an issue the person must drink three litres of fluid daily and avoid certain drugs known to affect kidney function including some over the counter painkillers like ibuprofen (Nurofen
®
). Hypercalcaemia is treated by drinking sufficient fluids or with medication such as bisphosphonates (biphosphonates such as alendronic acid and risedronate reduce bone break-down). If kidney damage is severe the person may require dialysis.
Advanced treatment
Advanced myeloma is when myeloma spreads from the initial cancerous area (called secondaries). Unfortunately there is generally no cure for advanced myeloma. Treatment aims to slow progression and improve quality of life. With proper treatment, a person with advanced can live for many years with a decent quality of life; treatment options include surgery, chemotherapy, radiotherapy and biological therapy.
Supportive therapy includes medication discussed earlier including painkillers and bisphosphonates (for bone problems), blood transfusions, antibiotics, drugs for anaemia, and growth factors. Many of these simply aim to prevent and treat side effects from chemotherapy. A palliative care team often takes over care at this stage with the aim of providing comfort to the patient and their family.
Pain relief
Many people suffering from myeloma will need some type of pain killer at some stage; pain can vary from mild to severe, depending on the extent of the condition and the amount of bone damage done. Many different painkillers may be used for pain relief from simple painkillers such as paracetamol to more potent painkillers like opioids (eg) morphine. Nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen and diclofenac are best avoided to prevent potential negative effects on the kidneys (which kidney already likely to be damaged due to myeloma). Nerve blocking drugs such as amitriptyline, carbamazepine, gabapentin or pregabalin may be needed if neuropathic (nerve) pain is an issue.
Corticosteroids may be used relieve bone pain in the later stages of the condition.
Radiotherapy and chemotherapy may help ease pain as it reduces abnormal cells. Surgery may be required for the likes of stabilisation of fractures and treatment of vertebral collapse.

Side effects
Side effects vary from person to person and drug to drug. Chemotherapy may cause severe side effects including fatigue, nausea and vomiting, loss of appetite, diarrhoea, constipation, and hair loss. Biological therapies in some cases can cause numbness or tingling in hands and feet (often only temporary). Myeloma can cause kidney damage or failure. For a small percentage the kidney damage can be permanent and the kidney function becomes so impaired that dialysis (artificial removal of waste and water from blood) is required; this usually means visiting your hospital for dialysis a few times a week.
Follow up care
Regular check-ups will be required after treatment is completed. At first, these check-ups will be frequent but gradually they will reduce. Follow-up checks will continue for at least 5 years.
Tests that form part of follow-up check-ups include physical exams, blood and urine tests, Xrays and scans.
The exact cause of myeloma is still unknown. There are risk factors that may increase the chance of developing myeloma. These include increasing age (myeloma is more common in older adults, especially over 60 ’s), gender (it is more common in men than women), race (it is more common in black people than white or Asian people), exposure to chemicals (petrol, oil, benzene, pesticides, paints, rubber, hair dyes …. studies suggest that workers in petroleum-type industries and those with many years exposure to hair dyes have more risk of myeloma.), exposure to viruses (such as HIV, hepatitis, herpes virus), exposure to radiation (especially dioxins), plasma cell conditions (eg. monoclonal gammopathy), other conditions (autoimmune diseases, pernicious anaemia or ankylosing spondylitis) and family history (if a person has a parent, sibling or child diagnosed with myeloma, their risk is thought to increase 2 and 6 fold).
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