Retrospective Analysis of Presentation, Treatment, and Outcomes of Multiple Myeloma at a Large Public Referral Hospital in Eldoret, Kenya

Global disparities in patients with multiple myeloma: a rapid evidence assessment

There are disparities in outcomes for patients with multiple myeloma (MM). We evaluated the influence of sociodemographic factors on global disparities in outcomes for patients with MM. This rapid evidence assessment (PROSPERO, CRD42021248461) followed PRISMA-P guidelines and used the PICOS framework. PubMed and Embase® were searched for articles in English from 2011 to 2021. The title, abstract, and full text of articles were screened according to inclusion/exclusion criteria. The sociodemographic factors assessed were age, sex, race/ethnicity, socioeconomic status, and geographic location. Outcomes were diagnosis, access to treatment, and patient outcomes. Of 84 articles included, 48 were US-based. Worldwide, increasing age and low socioeconomic status were associated with worse patient outcomes. In the US, men typically had worse outcomes than women, although women had poorer access to treatment, as did Black, Asian, and Hispanic patients. No consistent disparities due to sex were seen outside the US, and for most factors and outcomes, no consistent disparities could be identified globally. Too few studies examined disparities in diagnosis to draw firm conclusions. This first systematic analysis of health disparities in patients with MM identified specific populations affected, highlighting a need for additional research focused on assessing patterns, trends, and underlying drivers of disparities in MM.

Medical practitioners' knowledge and awareness of multiple myeloma at public hospitals, Gauteng, South Africa

BACKGROUND

 Multiple myeloma (MM) is a plasma cell malignancy associated with morbidity and mortality worldwide, and most patients are referred for specialist care very late with complications. The low index of suspicion among medical practitioners is among the reasons for the delay in MM diagnosis and management. This study aimed to determine the level of awareness and knowledge of MM among medical practitioners working in public hospitals of Tshwane Municipality, Gauteng Province, South Africa.

METHODS

 A cross-sectional descriptive study on 74 doctors working in three district, one regional and one central hospital using a convenience sampling.

RESULTS

 Seventy-four medical practitioners participated in this study. Their median age was 37 years with an interquartile range of 43-30 years. The majority (85%) of the respondents were aware of MM, while 74% were knowledgeable regarding MM presentations and diagnostic investigations.

CONCLUSION

 The findings highlighted a high level of awareness and knowledge of MM among the study population, but almost all of the participants requested an educational information brochure on MM.Contribution: Medical practitioners have a high level of awareness of multiple myeloma; however, there is a discrepancy between this level of awareness and the delayed presentation of patients at the public hospitals. As primary healthcare in South Africa is nurse-driven, the study indicates that not all primary healthcare providers may be aware of this disease. Future awareness campaigns should target other primary healthcare providers, including nurses and private general practitioners.

Immunophenotypic expression profile of multiple myeloma cases at a tertiary hospital in Nairobi Kenya

Introduction

Multiple myeloma (MM) is a plasma cell neoplasm that constitutes 10-15% of all hematopoietic neoplasms. Kenya is placed among the top five African countries for MM incidence and MM-related mortality. Prior studies have suggested that the aberrant expression of Cyclin D1, CD56, CD117 and Ki-67 on neoplastic plasma cells is useful in disease prognostication. The prevalence and significance of expression of these markers in a cohort of MM cases in Kenya has not been studied previously.

Methods

A retrospective cross-sectional study was carried out at the Aga Khan University Hospital, Nairobi. The study population included 83 MM cases with available trephine blocks archived between 1st of January 2009 and 31st of March 2020. Immunohistochemical expression of Cyclin D1, CD56, CD117, and Ki-67 was analyzed and scored. The biomarkers were described using frequencies based on the positive and negative results. Fisher's exact test was used to determine the association between the immunophenotypic markers and categorical variables.

Results

Of the 83 selected cases, expression of Cyclin D1, CD56, CD117 and Ki-67 was identified in 28.9, 34.9, 7.2, and 50.6%, respectively. Cyclin D1 positivity was significantly associated with hypercalcemia. Absence of CD117 expression was noted to be associated with adverse risk parameters including an IgA isotype or light chain disease, International Staging System (ISS) stage III disease, abnormal baseline serum free light chains (sFLC) and a high plasma cell burden.

Conclusion

Cyclin D1 expression was congruent with previously reported studies. The frequency of CD56 and CD117 expression was lower than previously reported. This may be due to differences in disease biology between the study populations. Approximately half of cases were Ki-67 positive. Our data showed limited associations between the expression of studied markers and clinicopathologic variables. However, this could be attributed to the small study sample size. We would recommend further characterization of the disease in a larger prospective study with the inclusion of survival outcomes and cytogenetic studies.

Are African primary physicians suspicious enough? Challenges of multiple myeloma diagnosis in Africa

Background

Multiple myeloma is a hematological malignancy of plasma cells belonging to a spectrum of monoclonal protein-secreting disorders known as paraproteinemias. It is classically characterized by accumulated plasma cells in the bone marrow, renal insufficiency, hypercalcemia, and bone lesions (CRAB). Despite studies in the USA indicating that the incidence of multiple myeloma is twice as much in Americans of African descent compared to white Americans and those of Asian descent, African countries have some of the lowest incidence rates and prevalence of the cancer. It is generally thought that this is not entirely factual given the paucity of research into the cancer in sub-Saharan Africa, coupled with other diagnostic challenges such as economic hardships, and poor health-seeking behaviors. In this mini review, we explored the state of multiple myeloma diagnosis across sub-Saharan Africa, outlining the challenges to diagnosis and proposing possible solutions.

Main body

Due to the lack of routine checkups in people > 40 years across sub-Saharan Africa, monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM) are often accidentally diagnosed. This is due to a very low awareness of multiple myeloma among primary care clinicians and the general population. Other major challenges to multiple myeloma diagnosis across Africa include a chronic shortage of human resource (pathologists, cytotechnologists, and histotechnologists), and a prohibitive cost of diagnostic services that discourages early diagnosis.

Conclusion

To improve multiple myeloma diagnosis in Africa, a systems approach to thinking among policy makers, philanthropic organizations, and oncologists must be adopted. Governments must invest in health insurance coverage for cancer patients concurrently with heavy investments in human resource training and diagnostic infrastructure scale up. Creative approaches such as digital pathology, online training of clinicians, research and capacity building collaborations among African institutions, European and American institutions, and pharmaceutical companies as seen with other cancers should be explored for multiple myeloma too.