Dr. Hannes Koornhof (Chairman of SACHAS) MBChB, FCP (SA), Dip HIV Man (SA), Cert Clin Haematology (SA) Phys
Most of you reading this would have probably never heard of such a disease. My hope is, after taking time to read this, that you will know what myeloma is and have a better understanding of bone marrow cancer in general. So, let’s get started!
Your bone marrow is the factory where all your blood cells are made. This includes red blood cells (they carry the oxygen in your blood), white blood cells (your body’s defence against infections) and platelets (small fragments that prevent and stop bleeding). The production of these cells by the bone marrow is very well controlled by your body, both in terms of the amount and the type of cells produced. If you have an infection, for instance, your body tells the stem cells in your bone marrow to make more white blood cells to help fight the infection. In such instances, an immature, baby cell gets produced in your bone marrow which then needs to go through various stages of growth and development to become a mature white blood cell. It is then released from the bone marrow into your bloodstream to go and do the job it was destined for, to fight the infection.
This process usually runs quite smoothly, but things can, unfortunately go horribly wrong. Sometimes your body makes a mistake in the production of a white blood cell, almost like a programming error which occurs in the DNA (blueprint) of the cell. It often recognizes its mistake and corrects it, but occasionally this abnormal cell has the ability to hide from your body’s defences, doesn’t listen to your body’s commands anymore and can start to increase in number without anything controlling it. This causes a variety of problems and is then called cancer. Depending on the type of white blood cell and where in its development the programming error occurs, a person can either develop a type of bone marrow cancer (usually leukaemia or myeloma) or lymphoma (glandular cancer), which is also a type of cancer that develops from an abnormal white blood cell.
That brings us to myeloma (also called “multiple myeloma” or “plasma cell myeloma”). Myeloma is a type of bone marrow cancer that develops when a programming error occurs in the development of a specific type of white blood cell, called a plasma cell. To understand myeloma better, it is important to understand what role a plasma cell plays under normal circumstances. They are indeed an integral part of your body’s immune system. Any infection that you may develop gets recognized by your plasma cells. They respond by rapidly producing small proteins called antibodies, which are almost like “homing missiles”, programmed to go and destroy only that specific virus or bacteria that is making you ill. After an infection, some of the antibodies remain in your bloodstream and if you are exposed to that exact virus or bacteria again, they are ready to attack immediately, thereby limiting the infection. This is the rationale behind childhood vaccination; to stimulate the production of antibodies which patrol your bloodstream and protect you when you get exposed to infections like measles, polio and many others.
If these plasma cells become cancerous however, they rapidly increase in number, taking over the bone marrow and producing a massive amount of an abnormal antibody which can cause a whole array of problems. This increase in antibody levels in the bloodstream can be measured with a blood test and is also used to monitor the response to treatment.
What are the symptoms of myeloma?
The abnormal plasma cells in the bone marrow overwhelms the normal bone marrow which most commonly leads to an inability to produce enough red blood cells. This is called anaemia. Symptoms of anaemia are related to the body’s inability to carry sufficient oxygen to your organs and include worsening fatigue, shortness of breath and dizziness.
The abnormal plasma cells also have the ability to weaken your bones. This can either be a generalized loss of bone strength (called osteoporosis), or it can lead to numerous holes being eaten in your bones. This can be seen on an X-Ray or other types of scans. It often results in significant bone pain or even worse, severe fractures with minimal- or even no trauma at all. Bones are rich in calcium, and if they are being eaten away, their calcium content is released into the bloodstream causing an elevated blood calcium level. This can lead to dehydration, kidney failure and numerous other symptoms.
As mentioned before, the plasma cells in the bone marrow releases a massive amount of abnormal antibodies into the bloodstream. They can clog up your kidneys and cause significant- and often irreversible kidney failure. This can seriously complicate the management of the disease.
These are by far the most common features of myeloma: anaemia, bone lesions or fractures, hypercalcaemia and kidney failure. There are numerous other symptoms which can occur, albeit less common.
Is myeloma treatable?
Myeloma is indeed a treatable condition, but there are a couple of important treatment principles to understand.
For most people, myeloma is not a curable disease. It can, however, be carefully managed and the aim of treatment is to provide a good quality of life for as many years as possible. No patient’s disease is the same and where we sometimes have patients with myeloma living in excess of ten years after being diagnosed, other patients are unfortunately less fortunate and have a form of the disease that is resistant to treatment which can take its toll after only a couple of months. We perform DNA-tests on the cancer cells and look at various other blood results in an attempt to identify those patients with high-risk disease, who potentially need more intense treatment than others.
The goal of treatment is to destroy as many abnormal plasma cells in the bone marrow as possible. This leads to recovery of the normal bone marrow and minimises the risk of any further complications, giving the body a chance to recover from any complications caused prior to treatment.
For many decades, the backbone of the treatment for myeloma was a combination of two different type of drugs: Chemotherapy and high dosages of cortisone. This is usually quite well tolerated. The last couple of years, however, have seen an explosion of newer therapies for the treatment of myeloma. This started years ago with the discovery that Thalidomide, was extremely effective for the treatment of myeloma. Soon, more of these so- called “novel therapies” were developed, leading to a significant increase in the survival of patients who have access to these drugs. The latest and most impressive of these treatments are certainly the development of monoclonal antibodies and CAR-T cells, both of which are extremely effective even in high risk or resistant myeloma. There is so much excitement about all the newer therapies, but access remains a challenge in the South African market. A strong collaborative effort is required amongst pharmaceutical companies, government and medical schemes, to improve the current access of newer drugs. Nevertheless, some of these drugs have been around for many years and the costs have come down considerably, making it accessible to more people.
The initial treatment of myeloma generally consists of varying combinations of these drugs depending on the patient’s age, physical condition and of course, the available funding. We usually use 3 different drugs in combination (a so-called “triplet” regimen) which has been proven to be very effective. Once the treatment is started, we take blood regularly to monitor the abnormal antibody levels in the blood which, as mentioned earlier, is a surrogate indicator of the number of cancer cells remaining in the bone marrow. If we don’t see a significant downward trend, the disease is likely resistant to that specific treatment combination and treatment should be adjusted accordingly. However, if the antibody levels come down significantly, we are on the right track and can continue with the same treatment until an optimal response is obtained or the development of side- effects forces us to make an adjustment.
After 4-6 months of treatment, the hope is to see no sign of any abnormal antibodies or cancer cells anymore (we call this a “remission”), or at least a dramatic reduction. We do however know that although we sometimes don’t pick up any sign of residual disease, it is merely because the available tests are not sensitive enough. There will always be some cancer cells that remain. As a general principle, however, the less residual disease, the longer it usually takes before it causes problems again. Because of this, we usually treat younger patients more aggressively in an attempt to obtain a deeper remission. The biggest difference in younger patients is the use of an autologous stem cell transplant as a 2nd phase of treatment to try and obtain or deepen a remission. We harvest the patient’s bone marrow stem cells and keep them frozen until needed. We then administer a single high dose chemotherapy which destroys many of the remaining cancer cells, but in the process, it also destroys the normal bone marrow, without which you cannot survive. The patient’s stem cells are then thawed and given back to them like a blood transfusion. After about two weeks of close monitoring in the hospital, the stem cells start to function and the patient subsequently has his/her own bone marrow back, hopefully with significantly less myeloma. The age cut-off for such a procedure is arbitrary because it largely depends on the physical condition of the patient. Most people in South Africa, however, use the age of 70 as a cut off, sometimes a bit older if the patient is in exceptional condition for his/her age. The median age of people diagnosed with myeloma worldwide is about 70 years. The available data, however, suggests that the median age in South Africa is considerably younger, somewhere around the age of 60 years. Due to this, as well as the problems with drug availability in South Africa, we often rely quite heavily on stem cell transplantation as an important part of treatment. If enough stem cells are harvested and cryopreserved, such a transplant can be repeated on numerous occasions to improve disease control.
After a transplant, as well as for those patients who are not candidates for a transplant, a form of low-intensity maintenance therapy is often started as the next phase of treatment in an attempt to keep the disease under control for as long as possible. This duration varies considerably. We hope for a couple of years, but it is unfortunately sometimes just a couple of months before the disease worsens, after which more intense treatment needs to be restarted again and the above cycle repeats itself. The remission duration gives us a good indication regarding the nature and prognosis of the disease.
There is so much more detail about myeloma to share, but the bottom line is this: Although myeloma is not a curable cancer and can lead to devastating complications, there is good treatment available which can help many patients enjoy a good quality of life for many years. It is important to diagnose myeloma early, so if you have some of the symptoms mentioned earlier, please contact your General Practitioner for further investigation. If any abnormalities are detected, your GP can refer you to a Clinical Haematologist, who specialises in bone marrow cancers and are best equipped to treat your myeloma. We are all very excited about the future of myeloma treatment and hope that the treating physicians, pharmaceutical companies and government can take hands to ensure proper treatment for all the people in South Africa who suffer from this disease.
This article was compiled by Dr. Hannes Koornhof (Chairman of SACHAS) MBChB, FCP (SA), Dip HIV Man (SA), Cert Clin Haematology (SA) Phys
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