Myeloma: Symptoms to diagnosis - PowerPoint Presentation

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Myeloma: Symptoms to diagnosisCan we do better?

[Hospital name][Date]

What is myeloma?

Cancer of plasma cells

Leads to:

Bone infiltration

- fractures (especially vertebral wedge fractures), hypercalcaemia

- painRenal damageAnaemiaImmunosuppression - infections

Novel therapies have dramatically improved survival in the last 15 years*Median overall survival improved from ~2  5 yearsYounger patients 7+ years

~5,700 cases per year in the UK

Median age: 72

* CRUK Myeloma Statistics:

http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/myeloma

How does myeloma present?

Myeloma is the cancer with the longest pathway to diagnosis in the UKMedian time to diagnosis: 163 days*

~1/3 present via emergency route

Does it matter?

Long time to diagnosis

 end organ damage – may be irreversible (kyphosis, dialysis, fatal infection)Survival at 12 months: 62% emergency admission vs 88%† GPPatient frustration & loss of trust in healthcare staff

Why?* Howell DA et al. BMC Hematol. 2013;13(1):9† Public Health England “Routes to Diagnosis 2006-2016”

Presenting symptoms are non-specific

The commonest myeloma symptoms are vague:

Back pain is common in non-myeloma population

Chest, abdominal, limb pain

etc

(not necessarily ‘bone pain’)Systemic symptoms – generally unwell

THINK MYELOMA: In any patient with persistent unexplained pain +/- generally unwell or anaemia of unknown cause  perform a myeloma screenData from TEAMM trial: Commonest presenting symptoms from 765 patients

Time from first symptom to seeing a haematologist

Median

time

(Days)

Intra-hospital delay

(Median IQR)51% referred direct to haematology by GP59N/A29% via acute services* (by GP or self referral)599d (2-30)21% via other non haematology speciality

e.g. Orthopaedics, Gastroenterology, Respiratory, Renal12030d (9-60)

Patients presenting via non-haematology or non-acute services experience long diagnostic delays (median 120 days)

TEAMM trial data. True diagnostic intervals will be greater because 1. patient recall of symptom duration is often underestimated, 2. does not account for time from 1st haematology appointment to histological confirmation* Acute services: A&E or Acute Assessment Unit

Myeloma screening tests

FBC, ESR, creatinine, calcium

Immunoglobulins, protein electrophoresis AND urinary

Bence

Jones protein or serum free light chains (

sFLC)Imaging*: skeletal survey is too insensitive  whole body CT, MRI, PET-CTInterpreting serum free light chains:Normally kappa and lambda light chains are excreted in similar amounts and the K:L ratio is close to oneIn inflammation and renal impairment, absolute levels K and L are higher but K:L ratio remains close to one98% of myeloma cases have a K:L ratio > 7.0 or < 0.08 and/or a paraprotein

>10g/l (caveat - will not detect non-secretory myeloma: rare <1% cases)* NICE guideline [NG35] February 2016

Monoclonal gammopathy of undetermined significance (MGUS)

Pre-malignant monoclonal plasma cell disorder

Myeloma is always preceded by MGUS

MGUS is common and incidence rises with age: age >50, incidence 3% (Caucasian heritage), 5-8% (African heritage)

Not all patients with a

paraprotein or abnormal FCL K:L ratio have myeloma – the majority do notRisk stratification for MGUS (score 1 for each factor*)Level of paraprotein > 15g/L

Non-IgG vs IgG (score 1 for non-IgG)Abnormal FLC ratioRisk of transformation to myeloma and follow up requirements (or not) are determined by these criteria*Rajkumar SV et al, Blood. 2005;106(3):812-7

Local pathways or protocols