The Crucial Role of Primary Care Providers in Myeloma Detection and Management
The journey towards diagnosing Multiple Myeloma, a cancer of the bone marrow, can often be long and complex, primarily due to the non-specific and heterogenous presenting symptoms of this insidious disease. Each patient’s journey towards their diagnosis is unique and may involve multiple visits to their Primary Care Provider (PCPs) before a diagnosis of Multiple Myeloma is finally made.
At Binding Site, part of Thermo Fisher, we are specialists at developing innovative diagnostic assays for the diagnosis and monitoring of Multiple Myeloma and other monoclonal gammopathies. Recently, we had the privilege of discussing the pivotal role of PCPs in Myeloma detection and management with Professor Andrew Spencer, Head of the Malignant Haematology, Transplantation and Cellular Therapies Service at The Alfred Hospital and Professor of Haematology at Monash University in Melbourne, Australia.
Symptoms of Multiple Myeloma can be hard to recognise
Unlike some other cancers, Myeloma can present with various and vague indications. Reflecting on how PCPs can effectively recognise the subtle signs and symptoms of Multiple Myeloma to minimise diagnostic delays, Professor Spencer commented “So it's not, like lung cancer where someone will come in with a cough or coughing up blood. It can present in many different ways. And it's really about taking a good history and reflecting upon what are the more common ways it may present, even though different patients present differently.”
Multiple Myeloma most frequently afflicts people over 60 years of age and common presenting symptoms are also often associated with the natural aging process “In about 2/3 of patients, bone pain is the principal manifestation. And what we mean by this is newly emergent bone pain or the sudden onset of back pain in the garden or something that's a little bit out of the ordinary. It's not just a patient coming along with the usual chronic lower back pain; it's newly emerging pain or pain that in fact becomes progressively worse. And I think that it's critically important, in that context, to have a very low threshold to undertake some form of radiological evaluation.”
Other symptoms that may point towards Myeloma include anaemia, progressive fatigue, weight loss, and sometimes fevers1. A careful patient history, focusing on these symptoms, coupled with simple diagnostic blood tests can aid in the early detection of the disease. "It really boils down to having an awareness or a suspicion and taking an appropriate history and appropriate first line investigations," Professor Spencer advised.
Patients with suspected Multiple Myeloma should be swiftly referred to a specialist
When it comes to referring patients to a specialist, Professor Spencer urges primary carers to act promptly upon receiving abnormal results that support the suspected diagnosis of myeloma. He emphasised the need for immediate referral to a haematologist, stating "There is no benefit whatsoever in delaying on referral as promptly as possible to an appropriate specialist clinician."
Expanding upon the need to refer to an appropriate specialist, Professor Spencer highlighted the complex nature of modern cancer management “most haematologists and oncologists really are starting to subspecialise. So, my advice if there's suspicion of myeloma patients should be referred as quickly as possible to an appropriate specialist in that space.”
Even when patients may seem well, the need for urgent referral is still pressing, Professor Spencer emphasised, “particularly patients with high light chain levels in their initial tests could have incipient renal failure and can rapidly progress to quite advanced renal failure unless action is taken promptly. Furthermore, patients may have critical bone lesions which can fracture, particularly if we're talking about lesions in the spine or the femur, the weight bearing bones.”
Primary carers can confidently aid in monoclonal gammopathy patient management
The Primary Carer's role extends beyond detection and referral, to include patient management. However, monoclonal gammopathies are a spectrum of conditions that many Primary Care Providers may not be familiar with and may feel uncomfortable managing patients. The Primary Carer’s involvement in patient management will vary with the type of monoclonal gammopathy involved. Professor Spencer offered his thoughts on this and gave some helpful advice for PCPs when monitoring patients with monoclonal gammopathies. “I think that a primary carer is ideally positioned to follow up patients with monoclonal gammopathy of undetermined significance [MGUS] and the frequency of evaluation would really be determined by the haematologist that's evaluated the patient. But in most cases, patients with MGUS, can be followed up every 6 to 12 months. And this follow-up would include taking a history from the patient. It would include basic haematology and biochemical analysis and also repeat measurements of serum protein electrophoresis and serum free light chain assays.”
Professor Spencer continued with advice on what to look out for and reiterated the support provided to PCPs by haematologists when needed. “And what you're looking for here is any incremental gain in the levels of paraprotein or involved light chain and it's not just one reading that's gone up, it's succession of rises in a reading and this would prompt further review by the haematologist. It may not indicate transformation to active Myeloma but it does indicate that further analysis of important parameters such as skeletal health and that review by a haematologist is required.”
In the case of active myeloma patients who have been treated, Professor Spencer noted that they typically continue to be monitored at the centre where they received treatment due to the complexity of the disease. However, for patients with restricted access to specialist centres, e.g. those living in rural areas, Primary Carers play a vital role in ongoing monitoring and well-being checks. “Primary carers are very much involved in the ongoing monitoring and the well-being of those myeloma patients because unfortunately we know that at some stage they're definitely going to relapse and it's important to detect once that relapse is emerging to avoid the development of any further end organ injury.”
In conclusion, Primary Care Providers play a pivotal role in the early detection, referral, and when appropriate, ongoing management of myeloma patients. Professor Spencer's insights underscore the importance of awareness, vigilance, and prompt action in dealing with this complex disease.
