Supportive care for multiple myeloma

Supportive care helps people meet the physical, practical, emotional and spiritual challenges of multiple myeloma. It is an important part of cancer care. There are many programs and services available to help meet the needs and improve the quality of life of people living with cancer and their loved ones, especially after treatment has ended.

Recovering from multiple myeloma and adjusting to life after treatment is different for each person, depending on the extent of the disease, the type of treatment and many other factors. The end of cancer treatment may bring mixed emotions. Even though treatment has ended, there may be other issues to deal with, such as coping with long-term side effects. A person who has been treated for multiple myeloma may have the following concerns.

Fatigue is a symptom of having a low red blood cell count (called anemia). Red blood cell counts in the bone marrow can be low when there are high numbers of plasma cells (called myeloma cells). Fatigue can also be a symptom of multiple myeloma treatment or other problems including poor nutrition, sleep problems, stress, anxiety or depression.

Once the cause of fatigue is known, your healthcare team can suggest ways to treat it. Treatments may include:

• nutritional supplements if you have poor nutrition
• iron pills or a blood transfusion for anemia
• medicine to make your body make more red blood cells (called erythrocyte growth factors)
• antidepressants for depression
• sleep medicine to help improve sleep

Find out more about fatigue and anemia.

White blood cell counts and antibody production can be low when multiple myeloma or its treatments affect the bone marrow. Both white blood cells and antibodies help fight infection. If the body has low numbers of white blood cells or antibodies, this can lead to infection.

Preventing infection is important for people with multiple myeloma. Having good hygiene, protecting your skin and maintaining good general health are some ways to help prevent infection. Your healthcare team may give you medicines to prevent infection or increase the number of white blood cells if you have a low white blood cell count, including:

• antibiotics, antivirals and antifungals – to treat infections
• colony-stimulating factors, such as filgrastim (Neupogen) or pegfilgastrim (Neulasta) – to increase white blood cell counts

Your doctor may also suggest immunizations for pneumococcal pneumonia and influenza (flu) to help lower your risk of getting an infection.

Find out more about infection, low white blood cell count and immunizations.

Bone pain is a common symptom in people with multiple myeloma. Bone pain can be a result of a buildup of myeloma cells in the bone. Bone pain can also occur if a bone breaks down or becomes fractured (broken). Treatments for bone pain and fractures may include:

• radiation therapy
• bisphosphonates
• pain medicines

You may be given pain medicines such as acetaminophen (Tylenol), dihydrocodeine, morphine (MS Contin) or fentanyl (Duragesic). But nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Motrin, Advil) or naproxen (Naprosyn, Aleve), aren’t usually given to people with multiple myeloma since they can increase the risk of kidney damage.

Nerve block

This procedure blocks pain by injecting a local anesthetic (freezing) and other drugs into or around a nerve or into the space around the spinal cord.

Vertebroplasty

Bone cement is injected into a fractured vertebra to stabilize it so it doesn’t move.

Kyphoplasty

When part of a vertebra collapses, a balloon is inserted into the collapsed area to raise it up. Bone cement can then be injected in the area that was collapsed to stabilize the vertebra.

Find out more about pain.

Bones that are fractured can cause nerves to get compressed (squished). This can cause nerve damage and pain. Treatments for nerve pain may include pain medicines such as gabapentin (Neurontin), amitriptyline (Elavil) or pregabalin (Lyrica).

Vertebroplasty and kyphoplasty also help take the pressure off nerves that are compressed if a bone is fractured. This helps to relieve nerve pain.

Some drugs used to treat multiple myeloma such as thalidomide (Thalomid) and bortezomib (Velcade) can cause peripheral neuropathy. Peripheral neuropathy causes pain, burning, numbness or feeling of pins and needles in the hands, arms, feet or legs. Treatments for peripheral neuropathy include:

• pain medicines such as gabapentin (Neurontin), amitriptyline or pregabalin
• lowering the dose of drugs used to treat multiple myeloma
• changing how often the drugs used to treat multiple myeloma are given
• acupuncture

Although there isn’t a lot of research, there is some evidence that acupuncture can help relieve peripheral neuropathy.

If peripheral neuropathy is severe, your doctor may need to stop treatment for a while.

Find out more about peripheral neuropathy.

Multiple myeloma can cause bone to break down. As bone breaks down, calcium enters the bloodstream. This can lead to high levels of calcium in the blood, a condition called hypercalcemia. You may feel constipated, have to urinate often or be weak or confused. Treatment for hypercalcemia may include:

• bisphosphonates
• drinking lots of fluids
• fluids given by vein (intravenously)

Find out more about hypercalcemia.

Some people with multiple myeloma develop kidney problems because of high blood calcium (hypercalcemia) or a buildup of M-proteins in the kidney. This can cause kidney damage. You will have regular tests to check how well the kidneys are working. If you have kidney problems, treatment may include:

• chemotherapy – which kills the myeloma cells that are making M-proteins and destroying bone
• drinking lots of fluids
• bisphosphonates
• plasmapheresis – treatment to remove plasma from the blood if the blood has a high amount of M-protein and becomes too thick (a condition called hyperviscosity)
• dialysis – used to clean waste products from the blood if the kidneys are severely damaged and are no longer working
• kidney transplant – may be needed in rare cases if the kidneys are severely damaged and are no longer working

Hyperviscosity means that the blood has become too thick (viscous). This can happen when the blood has a high amount of M-protein. Hyperviscosity can make you feel dizzy, weak and tired and can cause headaches. Treatment for hyperviscosity is called plasmapheresis. Plasmapheresis removes plasma containing M-protein from the blood.

Plasmapheresis lowers protein levels, but without further treatment protein levels will rise again. After plasmapheresis you may have chemotherapy or other drug therapy to lower the number of myeloma cells that make M-proteins.

Bisphosphonates can lead to death of the jaw bone, a condition called osteonecrosis of the jaw. This is a rare side effect of bisphosphonates, and doctors don’t know why it happens. It is more common in people who have dental surgery such as tooth extractions or periodontal surgery such as implants. Symptoms of osteonecrosis of the jaw include pain, swelling, loosening of teeth, numbness in the jaw, poor healing and infection. Treatments for osteonecrosis of the jaw include:

• antibiotics
• mouth rinses
• mouth prosthesis
• surgery to remove injured tissue or bone

Surgery can make osteonecrosis of the jaw worse, so it is only done when absolutely necessary.

People should have a complete dental exam before taking bisphosphonates. It is very important for people with multiple myeloma who take bisphosphonates to have regular dental checkups. Dental surgery should be done before taking bisphosphonates.

Emotions may be overwhelming during treatment and once treatment ends. Many people with multiple myeloma feel anxious and depressed.

During treatment, the focus is getting through treatment. Treatment takes a long time and it may be difficult to stay positive. You may be concerned about money, work and relationships.

When treatment is finished, you may have other thoughts and unexpected feelings, including:

• concern that the multiple myeloma will come back
• thinking of the effects of multiple myeloma on your family, friends and career
• questioning your self-worth and identity
• worrying about changes in your appearance
• adapting to lifestyle changes
• feeling anxious because you have less contact with the healthcare team

People cope with multiple myeloma in different ways. It may be helpful for you to:

• do appropriate physical activities
• have good nutrition
• balance being active with rest
• talk openly and honestly about your fears and concerns

Treatment for emotional distress may include counselling and medicines.

Learn more about life after cancer treatment and how to cope with your feelings and concerns.

Making some changes to your lifestyle and developing a wellness plan can help you to better cope with having multiple myeloma. Lifestyle changes can also help you stay healthy and feel better. You may find it helpful to:

• quit smoking
• eat better
• lower the amount of alcohol you drink
• exercise

But some types of high-impact exercise, such as jogging or contact sports, may lead to bone damage or fractures in people with multiple myeloma. Talk to your doctor or physiotherapist about which types of exercise are best for you.

Find out more about lifestyle changes and developing a wellness plan.

See a list of questions to ask your doctor about supportive care after treatment.