Assessing End-Stage Multiple Myeloma: Symptoms and Treatment Options

Q: Assessing End-Stage Multiple Myeloma: Symptoms and Treatment Options

Hello： 1. <br>The original physician from Hospital L has returned, and the physician from Hospital Z has asked you to go back to the original hospital for treatment, so it’s quite clear where to go. <br>2. <br>The symptoms of multiple myeloma are primarily related to the bone mar

End-stage assessment of multiple myeloma?

Dear Doctor,
My father was diagnosed with stage II multiple myeloma six years ago at the age of 65.
He did not undergo a stem cell transplant but chose treatment with CyBorD (cyclophosphamide, bortezomib, and dexamethasone).
For the first five years, his treatment response was quite good, with cancer markers even dropping below 5%, and his IgG levels were well controlled.
However, starting around March of last year, we suspected a relapse and switched to Revlimid (lenalidomide).
By March of this year, his IgG levels had risen to over 2400.
Two weeks ago, my father was hospitalized at his original hospital, L Hospital, due to pneumonia from a cold.
The attending physician mentioned he would be going abroad and could not continue my father's treatment, so he was referred to another hospital, Z Hospital, for emergency care.
He has been admitted there for a week, and there has been some improvement in his condition.
However, the hematology-oncology physician at Z Hospital believes my father should return to L Hospital since the original physician has returned to the country, and the medications covered by health insurance have already been approved there.
He mentioned that it might be more challenging to reapply for coverage at Z Hospital.
In this situation, should the family keep my father at Z Hospital or return him to L Hospital for treatment? Whose advice should we follow? Additionally, I would like to inquire about the criteria for determining end-stage multiple myeloma.
Besides laboratory tests, what physical symptoms might indicate this stage? At what point or under what conditions would a doctor recommend palliative care? Since I am working in another location and have not been able to meet with the doctors at the hospital, I can only seek information online.
Thank you for your response.

Miss Wang, 40~49 year old female. Ask Date: 2017/05/23

Dr. Chen Yunfang reply Oncology

Hello: 1.
The original physician from Hospital L has returned, and the physician from Hospital Z has asked you to go back to the original hospital for treatment, so it’s quite clear where to go.
2.
The symptoms of multiple myeloma are primarily related to the bone marrow.
As the cancer progresses, blood cell counts and anemia levels will continue to decline, leading to frequent blood transfusions for the patient.
During exacerbations, patients often experience bone pain and are at a high risk of fractures, which can impair mobility.
Tumor markers may rise significantly, often reaching tens of thousands (in my experience, usually around 20,000 to 30,000 is the last recorded number).
3.
Most patients with advanced multiple myeloma die from infections, such as pneumonia or sepsis.
By this stage, their blood cell immunity is severely compromised, making infections particularly dangerous.
Even the best antibiotics may not be effective, and once septic shock occurs, patients can deteriorate rapidly, often within 1-2 days.
The changes can be quite dramatic and unpredictable.
Therefore, it is rare for physicians to arrange for multiple myeloma patients to be admitted to hospice care in advance, as it is very difficult for them to estimate when a patient will truly pass away.
Thank you!

Reply Date: 2017/05/23

More Info

Assessing end-stage multiple myeloma involves understanding the symptoms, treatment options, and the overall management of the disease. Multiple myeloma is a type of blood cancer that affects plasma cells in the bone marrow. As the disease progresses, particularly in its end stages, patients may experience a variety of symptoms and complications that can significantly impact their quality of life.

Symptoms of End-Stage Multiple Myeloma
In the end stages of multiple myeloma, patients may exhibit several physical symptoms, including:
1. Anemia: Patients often experience fatigue, weakness, and pallor due to low red blood cell counts.

2. Bone Pain: Myeloma can lead to bone lesions and fractures, causing significant pain and mobility issues.

3. Increased Infections: The immune system is compromised, making patients more susceptible to infections such as pneumonia or sepsis, which can be life-threatening.

4. Hypercalcemia: Elevated calcium levels in the blood can lead to confusion, constipation, and kidney problems.

5. Renal Failure: Kidney function may decline due to the high levels of proteins produced by myeloma cells, leading to further complications.

6. Neurological Symptoms: Patients may experience numbness, tingling, or weakness due to nerve compression from bone lesions.

Treatment Options
In terms of treatment, the focus in end-stage multiple myeloma often shifts from curative intent to palliative care, aimed at relieving symptoms and improving quality of life. Options may include:
1. Chemotherapy: While aggressive treatment may not be feasible, some patients may still benefit from lower-intensity chemotherapy regimens.

2. Targeted Therapy: Medications like proteasome inhibitors (e.g., bortezomib) or immunomodulatory drugs (e.g., lenalidomide) may still be used depending on the patient's condition.

3. Supportive Care: This includes pain management, blood transfusions for anemia, antibiotics for infections, and hydration for kidney support.

4. Palliative Care: This approach focuses on providing relief from symptoms and stress, improving the quality of life for both the patient and the family.

Decision-Making Regarding Hospital Transfer
Regarding the decision of whether to keep your father at Z hospital or return him to L hospital, it is essential to consider several factors:
- Continuity of Care: If L hospital has a more established treatment plan and familiarity with your father's case, returning there may provide a more seamless transition in care.

- Access to Medications: If L hospital has already approved certain medications under insurance, it may be more beneficial to continue treatment there rather than starting anew at Z hospital.

- Current Condition: If your father is stable and responding to treatment at Z hospital, it may be worth discussing with the healthcare team there about the potential for continued care before making a transfer.

When to Consider Hospice or Palliative Care
The decision to transition to hospice or palliative care typically arises when:
- The patient has a limited life expectancy (often defined as six months or less).

- The focus shifts from curative treatment to comfort measures.

- The patient experiences significant symptoms that are not manageable with current treatments.

In conclusion, navigating the complexities of end-stage multiple myeloma requires careful consideration of symptoms, treatment options, and the best course of action for the patient’s care. Engaging in open discussions with healthcare providers, understanding the patient's wishes, and considering the family’s perspective are crucial in making informed decisions. It is advisable to consult with the healthcare team to clarify any uncertainties and ensure that your father's care aligns with his needs and preferences.

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