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Quality of life

Unmet needs and impact on quality of life

The introduction of drugs with novel mechanisms of action have significantly improved overall survival in multiple myeloma and quality of life years gained have become an important goal of therapeutic strategies

Francesca Patriarca MD Hematology, DISM, University of Udine, Italy; Working Party MM G.I.M.E.M.A

Outstanding advances have been made in the treatment of multiple myeloma (MM) patients during the last 20 years. In the 1990s, high-dose therapy with reinfusion of autologous stem cells, and in the next decade, the introduction of drugs with novel mechanisms of action, namely bortezomib and

immunomodulatory agents such as thalidomide and lenalidomide, have significantly improved overall survival by approximately 50% in patients younger than 65 years, while improvements in prognosis have been less pronounced in older patients.1–2

However, MM remains

an incurable disease and most patients will relapse and ultimately die because of their disease. Therefore, clinical research in the field of MM field is still geared to preserving life rather than just improving quality of life (QoL).

However, QoL years gained by effective treatments has become an important goal of therapeutic strategies. The factors affecting QoL of MM patients have two possible origins: (1) Symptoms and signs of overt disease that can be present at diagnosis and at the time of relapse

(2) Adverse events of MM treatments (Table 1).

Common clinical features The most common clinical features of MM are bone disease, anaemia and renal failure. Treatment toxicities in the ‘era of new drugs’ are mainly non- haematological and are represented by


Table 1: Factors affecting quality of life in multiple myeloma and their management

Symptoms/ signs affecting quality of life

Depending on multiple myeloma

Bone disease Anaemia Renal failure

Depending on

treatments Frailty Neurotoxicity Thrombosis Standard management

– Diagnosis with skeletal X-ray – Treatment with bisphosphonates (pamidronate or zolendronate) for two years in patients with bone lytic lesions undergoing anti-myeloma therapy

– Red cell transfusions – Epoietin-stimulating agents in case of Hb level < 10 g/dl

Correct potential precipitant factors, such as dehydration, hypercalcaemia, hyperuricaemia, urinary infections and concomitant use of nephrotoxic drugs

Reduced dosage of drugs: dexamethasone 80mg monthly, lenalidomide 10–15mg daily, thalidomide 50–100mg daily, bortezomib 1,3mg weekly

EMG and neurological evaluation before and during treatment Symptomatic treatment with gabapentin, pregabalin, and vitamin B complex compounds

During thalidomide or lenalidomide treatment: – prophylaxis with aspirin 100mg daily if no or any individual/MM thrombotic risk factor is present

enoxaparin 40mg once daily or full dose warfarin (target INR 2–3) if two or more individual/MM thrombotic risk factors are present

– Trimetoprim-cotrimoxazole to P. carinii prophylaxis during high-dose dexamethasone

– Acyclovir or valacyclovir for Herpes varicella zoster prophylaxis during bortezomib and combinations

neurotoxicity, thromboembolic diseases, infections and general poor treatment tolerance in elderly patients with multiple comorbidities. It can be hypothesised that QoL can be improved through different interventions: diagnostic tools to precociously identify signs of disease and treatment toxicity; more effective and tolerable therapies; and strategies of palliative care. Table 1 summarises the standard management of the most common MM symptoms and adverse events of anti-myeloma treatments. Issues in QoL that have greatly changed in recent years and need further research, namely bone disease, management of elderly unfit patients and neurotoxicity, are discussed.

Bone disease

Bone disease is present in 70% of patients at diagnosis and during the course of the disease; it is characterised by lytic lesions, vertebral collapses, fractures and rarely plasmacytomas in bones or soft tissues. Bone involvement is a frequent cause of clinical symptoms such as bone pain and neurologic defects in case of spinal cord compression by vertebral plasmacytomas. Skeletal X-ray has been the standard tool for detecting lytic lesions, upgrading MM stage and indicating need of treatment. However, X-rays have two important limits: scarce sensibility, demonstrating bone lesions when at least 50% of bone tissue has been lost; and lack of usefulness for demonstrating bone


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