Treatment and management of multiple myeloma (MM) is continuously evolving, and in this analysis, investigators discuss ever-present issues and potential solutions to optimize care for this patient population.
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“A careful balance between treatment efficacy and its tolerability should be considered for every patient,” they write. “A close monitoring of comorbidities, disease-related manifestations and treatment side effects is recommended, as well as a proactive approach, with reinforcement of information and patient awareness for the early recognition of adverse events, allowing prompt therapeutic adjustments.”
Complications most frequently observed in patients with MM—whose median age at diagnosis is 65 years and in whom frail status is frequently observed—are many and include infections, kidney injury, neurologic manifestations, cardiovascular involvement, hemostatic abnormalities, and bone disease.
For infections, it’s important to recognize that increased susceptibility in the setting of MM can frequently be attributed to disease-, patient-, and treatment-related factors, including immune suppression, age and comorbidities, and neutropenia, respectively, for example. It’s also vital to identify risk factors such as high tumor burden, low hemoglobin, and renal dysfunction that increase the likelihood of early and severe infections. Doing both things can help to facilitate individualizing prophylactic treatment.
Where the kidneys are concerned, initial patient evaluation should cover levels of serum urea, creatinine, electrolytes, and serum free light chain; urine protein electrophoresis; and 24-hour urine free light chain levels. Ongoing monitoring should encompass characterization of proteinuria for patient therapy response and potential disease progression, with additional complications that include renal biopsy, nephropathy, and hypercalcemia.
Hyperviscosity syndrome and central nervous system (CNS) involvement are common neurologic manifestations of MM that clinicians need to be aware of. Dizziness, frequent headache, tinnitus, and difficulty concentrating are typical presenting symptoms of hyperviscosity syndrome. For CNS involvement, the study authors note that although this is rare in MM, it typically occurs in the setting of progressive disease; therefore, they note the necessity of imaging via CT and MRI, as well as cerebral spinal fluid analysis to prevent neurological deterioration and optimize patient outcomes.
The study authors then highlighted how cardiovascular involvement with MM is either indirectly related to MM, such as through certain patient comorbidities (eg, diabetes, obesity); directly related (eg, hyperviscosity and high-output heart failure); or stemming from treatment toxicity, such as anthracyclines, alkylating agents, and immunomodulatory drugs. They believe it best that patient cardiac evaluation include an assessment of cardiac function, discussion of risk factors for cardiac toxicity, testing for potential AL amyloidosis, and monitoring/management during treatment.
Hemostatic abnormalities can include thrombotic complications, particularly venous thromboembolism (VTE), so clinicians should consistently monitor for risk factors that include recent surgery, trauma, previous VTE, and heart disease, among others. Hemorrhagic complications are also important to monitor for as a hemostatic abnormality; these usually happen in the setting of disease progression and are associated with thrombocytopenia, abnormal screening coagulation test results, and a history of bleeding.
The study authors highlight that bone disease complications connected to MM typically result from plasma cell proliferation and alterations to bone remodeling, which most frequently lead to bone pain. Managing this pain is primarily palliative in nature and meant to stabilize or improve patient quality of life. Palliative care in this setting is usually antiresorptive therapy with the goal of preventing new lesions, radiotherapy, surgery, corticosteroids, and analgesia. Other treatments to consider are vertebroplasty and kyphoplasty for pain associated with vertebral collapse.
Additional areas the authors cover in this guidance include chronic and acute pain, metabolic disorders, neuropsychiatric symptoms, ocular disorders, cutaneous lesions, gastrointestinal manifestations, second primary malignancies, teratogenic risk, toxicities associated with autologous stem cell transplant, and toxicities associated with T-cell engaging therapies.
Overall, the authors underscore the importance of recognizing and managing infections promptly in MM to minimize complication risk and optimize patient outcomes, and they emphasize that the high symptom burden and profound impact on quality of life from the disease and treatment-related toxicities make necessary treatment personalization and monitoring.
“Rapid and appropriate intervention on treatment-related adverse events and on worsening of comorbidities should be based on scientific evidence, consensus recommendations, clinical experience, and is of extreme importance for patients and their families,,” they conclude, “impacting the prognosis and quality of life of those who suffer daily with MM.”
Reference
Geraldes C, Roque A, Sarmento-Ribiero AB, et al. Practical management of disease-related manifestations and drug toxicities in patients with multiple myeloma. Front Oncol. 2024;14:1282300. doi:10.3389/fonc.2024.1282300
