Presentation and survival of multiple myeloma patients in Ghana: a review of 169 cases

Laboratory practice is central to earlier myeloma diagnosis: Utilizing a primary care diagnostic tool and laboratory guidelines integrated into haematology services

Treatment advances have greatly improved survival, but myeloma is among the worst of all cancers for delayed diagnosis, causing serious morbidities and early deaths. This delay is largely because the symptom profile of myeloma has very low specificity, and in primary care, myeloma is rare. However, initiating the journey to diagnosis simply requires considering myeloma and sending blood to test for monoclonal immunoglobulin. Laboratory tests reliably detect monoclonal immunoglobulin, which is present in 99% of myeloma cases, so why do health care systems have such a problem with delayed diagnosis? The Myeloma UK early diagnosis programme has brought together diverse expertise to investigate this problem, and this article was prepared by the programme's working group for laboratory best practice. It reviews evidence for test requesting, analysis and reporting, for which there is large variation in practice across the United Kingdom. It presents a 'GP Myeloma diagnostic tool' and how it can be integrated into laboratory practice alongside a laboratory best practice tool. It proposes improved requesting and integration with haematology services for reporting and interpretation. Here the laboratory has a central role in creating efficient and cost-effective pathways for appropriate and timely bone marrow examination for myeloma diagnosis.

Profile and outcome of multiple myeloma with and without HIV treated at a tertiary hospital in KwaZulu-Natal, South Africa

OBJECTIVES

To profile the outcome of multiple myeloma (MM) patients treated at a South African tertiary hospital in KwaZulu-Natal (KZN) and to compare MM in HIV-negative patients and MM in people living with HIV (PLWH).

METHODS

A retrospective analysis of patients with MM was conducted over 5 years (2015-2020). Patient demographics, presenting complaints, symptom duration, disease stage, molecular profile, treatment, and survival data were captured. Statistical analysis was conducted using R Statistical software of the R Core Team, 2020, version 3.6.3.

RESULTS

135 patients; 79% (n = 106) HIV-negative and 21% (n = 29) PLWH were investigated. 54% (n = 74) females and 57% (n = 76) 51-70-year-olds. The 40-50-year-old patient group had a significantly higher proportion of PLWH (p = 0.032). Pathological fractures were the commonest presenting complaint, 47% (n = 57 and 49% (n = 49) had International Staging System, stage III disease. Fluorescent in-situ hybridization (FISH) MM profiling was completed in 58% (n = 78). Positivity for del 11q22 was found in 23.7% (n = 14) with significantly more HIV-negative patients having the mutation (p = 0.027). Overall, 42.2% (n = 57) achieved 2-year overall survival (OS). There were no significant differences in treatment (p = 0.926) and 2-year survival outcome (p = 0.792) between the two groups.

CONCLUSION

The incidence of HIV in newly diagnosed MM patients in KZN was increasing. KZN patient profile differed from other reports by showing female predominance but was similar in advanced-stage presentation and bone fracture predominance. Statistically significant differences between the HIV-negative patients and PLWH were observed in age distribution and mutational landscape. Further studies are required in this area.

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.

Response and Survival Estimates of Patients With Plasma Cell Myeloma in a Resource-Constrained Setting Using Protocols From High-Income Countries: A Single-Center Experience From Sri Lanka

There is a significant disparity in global cancer care and outcome between countries. Progress in the treatment of symptomatic plasma cell myeloma (PCM) in high-income countries is not seen in low- and middle-income countries.

Is it possible to set up dedicated hemato-oncology centers and use protocols from high-income countries in a resource-constrained setting? It is possible to successfully apply treatment and supportive care protocols in the correct setting of dedicated hemato-oncology centers. Patients with plasma cell myeloma were treated with thalidomide- and/or bortezomib-containing regimens adapted from high-income countries. After a median follow-up of 40.6 months (range, 35.2-59.07 months), the median overall survival (OS) was 84.2 months (95% CI, 60.87 to NA) and the 5-year estimated OS was 65%, comparable to parameters in phase III randomized trials in high-income countries.

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.

Building a Sustainable Comprehensive Multiple Myeloma Program in Western Kenya

Despite improved treatment strategies for multiple myeloma (MM), patient outcomes in low- and middle-income countries remain poor, unlike high-income countries. Scarcity of specialized human resources and diagnostic, treatment, and survivorship infrastructure are some of the barriers that patients with MM, clinicians, and policymakers have to overcome in the former setting. To improve outcomes of patients with MM in Western Kenya, the Academic Model Providing Access to Healthcare (AMPATH) MM Program was set up in 2012. In this article, the program's activities, challenges, and future plans are described distilling important lessons that can be replicated in similar settings. Through the program, training on diagnosis and treatment of MM was offered to healthcare professionals from 35 peripheral health facilities across Western Kenya in 2018 and 2019. Access to antimyeloma drugs including novel agents was secured, and pharmacovigilance systems were developed. Finally, patients were supported to obtain health insurance in addition to receiving peer support through participation in support group meetings. This article provides an implementation blueprint for similar initiatives aimed at increasing access to care for patients with MM in underserved areas.

Lessons Learned Treating Patients with Multiple Myeloma in Resource-Constrained Settings

PURPOSE OF REVIEW

Based on personal experiences, recommendations for physicians treating patients with multiple myeloma (MM) in low- and middle-income countries (LMICs) are proposed.

RECOMMENDATIONS

(1) Implement strategies to keep the patient in the best possible condition for the longest time, in addition to focusing on ways to avoid financial toxicity; (2) if lenalidomide is unavailable, start treatment with thalidomide and dexamethasone, include, if possible, bortezomib; (3) conduct an outpatient-based autologous stem cell transplantation (ASCT) in all eligible patients; (4) use thalidomide as post-ASCT maintenance treatment if lenalidomide is unavailable for the standard risk patients; (5) monitor monoclonal proteins with serum protein electrophoresis and free light chain measurements; (6) employ novel drugs in cases of relapsed or refractory disease; and (7) do not forget supportive therapy. The therapeutic recommendations to treat patients with MM are somewhat different for physicians working in LMICs, compared with those treating patients in high-income countries. These are relevant since more than 50% of the inhabitants of the world live in LMICs, thus indicating that the vast majority of patients with MM are being treated in resource-constrained settings. As time goes by, physicians may acquire the ability to analyze and express their feelings and experiences about topics in the practice of medicine in which they could have learned lessons (1). Since 1980, we have been treating patients with multiple myeloma (MM); to date, we have been personally involved in the study and treatment of more than 300 patients with this disease (2). Having gained experience dealing with MM patients in underprivileged circumstances, such as those prevailing in our country: México, having explored different ideas, treatments, and methods, and being aware of the financial implications which may impact our selection of therapeutic strategies and recommendations, we felt that it was appropriate to share in this article some of these ideas with practitioners around the world who are involved in the treatment of patients with MM in low- and middle-income countries (LMICs).

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

PURPOSE

Treatment patterns and survival outcomes of patients with multiple myeloma (MM) in Kenya have not been adequately characterized. The objectives of this study were to describe the clinical, laboratory, and imaging findings at diagnosis, to describe the treatment offered, and to determine the survival outcomes of patients with MM over an 11-year period.

PATIENTS AND METHODS

A retrospective chart review was carried out for all patients who were diagnosed and treated for MM at Moi Teaching and Referral Hospital from 2009 to 2019. The Kaplan-Meier method was used to estimate survival. Factors affecting survival were identified using univariate and multivariate analyses.

RESULTS

A total of 221 patient charts were analyzed of which 124 belonged to male patients (56.1%). The median age at diagnosis was 61 years. Bone pain was the most common presenting complaint observed in 69.6% of 194 patients assessed. Out of 102 patients who received imaging studies, 60 (58.8%) had lytic lesions, 30 (29.4%) had fractures, whereas 30 (29.4%) had spinal cord compression. Anemia, renal failure, and hypercalcemia were observed in 87/187 (46.5%), 22/161 (13.7%), and 23/42 (54.8%) patients, respectively. Thalidomide and dexamethasone (65.2%); bortezomib, thalidomide, and dexamethasone (14.6%); and melphalan and prednisolone (11.9%) were the most prescribed initial chemotherapy regimens among 219 patients analyzed. Overall survival at 1 and 5 years was 70% and 21%, respectively; median overall survival was 29.0 months. In multivariate analysis, male sex (hazard ratio [HR] 1.9), baseline anemia (HR 1.8), and baseline renal failure (HR 3.2) were associated with significantly shorter survival.

CONCLUSION

Survival outcomes were poor despite increased use of multiagent-based chemotherapy regimens. Greater access to available diagnostics and treatments is required to achieve rational treatment and increased survival.

Effects of Amyloid Light-Chain Amyloidosis on Clinical Characteristics and Prognosis in Multiple Myeloma: A Single-Center Retrospective Study

BACKGROUND

Amyloid light-chain amyloidosis (AL amyloidosis) is commonly associated with multiple myeloma. However, the clinical characteristics and prognosis of symptomatic and smoldering multiple myeloma with AL amyloidosis are not particularly clear.

METHODS

Patients with symptomatic and smoldering multiple myeloma in the Peking University First Hospital registry from 2010 to 2018 were studied. The clinical and laboratory information was collected from first presentation to death or until the last available clinical follow-up. The patients' survival and outcomes were analyzed, and the relationship between the clinical parameters and survival was also assessed.

RESULTS

Compared with symptomatic multiple myeloma patients without AL amyloidosis, patients with AL amyloidosis had higher incidence of BNP≧700pg/mL (P<0.001), ALP>187.5IU/L (P=0.032) and ALB<25g/L (P<0.001). Similarly, compared with smoldering multiple myeloma patients without AL amyloidosis, patients with AL amyloidosis had higher incidence of BNP≧700pg/mL (P=0.030) and Alb<25g/L (P=0.024). The existence of AL amyloidosis, especially those with the heart involvement, was related to shorter long-term survival of symptomatic and smoldering multiple myeloma according to univariate analyses. Renal involvement and gastrointestinal tract involvement had an impact on the prognosis of smoldering multiple myeloma but not on the symptomatic multiple myeloma. Cox regression model for overall survival detected BNP≧700pg/mL in symptomatic multiple myeloma having independent poorer prognostic significance (HR=2.455, P=0.004). Interestingly, BNP at diagnosis was significantly correlated with cardiac amyloidosis (r=0.496, P<0.001). Cox regression model for overall survival detected the presence of AL amyloidosis in smoldering multiple myeloma having independent poorer prognostic significance (HR=8.741, P=0.002).

CONCLUSION

AL amyloidosis is an independent poor prognostic factor for not only symptomatic multiple myeloma but also smoldering multiple myeloma. It is mainly because of involvement of important organs, especially the heart. AL amyloidosis probably has a greater impact on the prognosis of smoldering multiple myeloma than on the symptomatic multiple myeloma.

The status of jaw lesions and medication-related osteonecrosis of jaw in patients with multiple myeloma

BACKGROUND/PURPOSE

Myeloma jaw lesions are not uncommon. The study aimed to investigate the status of jaw lesions and medication-related osteonecrosis of jaw (MRONJ) in multiple myeloma (MM) patients.

METHODS

One hundred and twenty-two consecutive newly-diagnosed MM patients seeking dental care at a hospital of southern Taiwan was examined according to jaw lesions with complete follow-up data.

RESULTS

Median age of the patients was 67.8 years, and 88.5% of patients were of DS stage III and 41.0% were of ISS stage III at diagnosis. Median survival was 37.9 months for 43 (35.2%) patients with jaw lesions and 57.4 months for 79 patients without jaw lesions. 1-year, 5-year and >7-year overall survival rates for patients with jaw lesions versus patients without jaw lesions were 94.9%, 67.2%, 56.7% vs 83.7%, 51.8%, 26.8% respectively. Patients with jaw lesions had the worse survival (P = 0.03). Neither age nor stage affected survival. Jaw lesions involved the mandible more often than the maxilla and stopped progressing during remission, but did not repair. Jaw lesions were the first evidence or recurrent sign of MM in six (4.9%) patients. Long-term monthly antiresorptive therapy changed the radiographic patterns of jawbones and induced MRONJ developing in 16.7% (8/48) of patients. Five (62.5%) MRONJ sites spontaneously occurred without local risk factors.

CONCLUSION

Nearly one-third of MM patients develop osteolytic jaw lesions that seem to be associated with poorer survival. Jaw lesion is an independent prognostic predictor of survival in myeloma. Antiresorptive drugs at less frequent dosing regimen are crucial to minimize spontaneous MRONJ.