Multidisciplinary Management of Multiple Myeloma in Older Adults

08/17/17
Citation

Journal of Clinical Pathways. 2017;3(6):45-48.

Affiliation

Department of Family Medicine, Prince George’s Hospital, Cheverly, MD; The Access Group, Berkeley Heights, NJ.

Correspondence

Dr Richard G Stefanacci

400 Connell Drive, 2nd Floor

Berkeley Heights, NJ 07922

Phone: (908) 508-6714

Email: rstefanacci@theaccessgp.com

Disclosures

Drs Tavakoli, Khan, and Knowles report no relevant financial relationships. Dr Stefanacci is the chief medical officer for The Access Group, a managed markets agency for pharmaceutical companies.

Abstract: Multiple myeloma (MM) is a progressive and fatal disease, primarily affecting men aged 66 years or older. Because MM is primarily a disease of the elderly, it is incumbent on geriatricians and primary care providers to understand the best course of management for their patients with this disease. Although the acute management of MM is driven by specialists, the identification of MM and management outside of the oncologist’s office will fall to geriatric care providers. In this article, the authors review information to guide the appropriate management of older adults with MM and discuss issues that may arise from the multidisciplinary management of this patient population.  

Received April 2, 2017

Accepted July 14, 2017

Multiple myeloma (MM) accounts for roughly 1% of all cancers in the United States and affects all races and geographics, although a greater incidence has been seen in individuals of African descent.1-3 The disease occurs more frequently in men, especially those aged 66 years or older. It is also seen in those with a higher body mass index.4

Because MM occurs most commonly in older adults, primary care providers (PCPs) and geriatric specialists need to be well versed in its management. In this article, we review the current information about diagnosing and caring for older adults with MM in order to guide multidisciplinary care for this patient population, many of whom might be frail.

Pathophysiology Overview 

MM is a fatal disease characterized by the proliferation of plasma cells that turn malignant and produce lytic lesions at multiple bony sites, including skull, ribs, vertebrae, and long bones of extremities, with concomitant IgM or IgG antibody production.5 The overexpression of light chains can then deposit in the kidneys, causing renal failure; deposits also occur in the bone marrow, causing bone pain, hypercalcemia, anemia, and increased susceptibility to infections.5 As such, it is important that these patients receive vaccines yearly pneumococcal pneumonia and influenza vaccines from their PCPs.6

Most cases of MM tend to start as monoclonal gammopathy of undetermined significance (MGUS). Although this is stipulated, the steps of this transformation process remain unknown, and there are postulations of several events that may take place for MGUS to change into MM.5 The formation of MGUS is thought to occur when antigens are presented to B cells, from which cell formation abnormalities follow. About half arise from B-cell immunoglobulin heavy locus translocation, while half are seen to be a cause of hyperploidy; less likely, it is a combination of both.7

It is believed that multiple random events occur when MM forms from MGUS, including secondary translocations, Ras mutations, p16 methylation, p53 mutations, increased cell production due to abnormal cell cycle, avoidance of apoptosis, increased angiogenesis, or IL-6 in bone marrow.8 Depending on which translocation is picked up, the disease can be categorized into different risk groups, and treatment is tailored to the specific risk group.9



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