MYELOMA DIAGNOSIS PATHWAY

Myeloma is a difficult cancer to diagnose due to the vagueness of symptoms and rarity of the disease
This is a tool designed to assist GPs and other healthcare professionals in recognising myeloma
In the UK, 5,700 people are diagnosed with myeloma every year
Myeloma patients experience some of the longest delays in diagnosis of all cancer patients

Suspect myeloma?

Myeloma red flags

Persistent pain (>4-6 weeks) especially back/bone pain or fractures

Weakness and fatigue

Recurrent or persistent infections

Unexplained anaemia

Nose bleeds, abnormal bruising

CRAB denotes four features of myeloma

Calcium raised

Vomiting, nausea, constipation, confusion, bone pain, polyuria

Up to 30% of myeloma patients present with hypercalcaemia.

Renal impairment/failure

Raised creatinine

Renal impairment occurs in 20-30% of patients at diagnosis.

Anaemia

Fatigue, shortness of breath

Around three-quarters of patients have anaemia at presentation.

Bone disease

Bone pain, loss of height, pathological fracture, spinal cord compression

60% of patients present with pain.
80-90% have lytic bone lesions at diagnosis.

Think myeloma!

If you suspect myeloma, request the following:

Full blood count and blood chemistry

FBC: Look for unexplained normocytic normochromic anaemia. Haemoglobin levels may be decreasing over time
ESR: Typically markedly raised, but may be normal in non-secretory or light chain myeloma
U&Es: Raised urea and creatinine may be a sign of significant renal deterioration

Serum/urinary protein measurement

Serum protein electrophoresis to check for the presence of paraprotein
Serum immunoglobulin level - look for immune paresis, except for paraprotein
Urine protein electrophoresis to check for light chains (Bence Jones protein) in urine
Serum free light chain (SFLC) assay, if available, may show an abnormal ratio

Refer

Contact/refer to the haematology clinic if the investigations show abnormal results, or in cases of unresolving presenting symptoms.

Check the NICE suspected cancer referral guidelines.

Early diagnosis via GP referral is associated with improved overall survival.

62% one year survival for patients diagnosed via emergency route

88% one year survival for patients diagnosed via GP referral

Further tests

(haematology clinic)

Imaging tests

Imaging tests to assess for myeloma-related bone disease include:

Skeletal survey
Whole-body MRI
Low-dose CT

Isotope bone scans should not be used.

Bone marrow biopsy

Bone marrow aspirate and trephine to confirm diagnosis and determine plasma cell percentage and phenotype.

Diagnose myeloma

Myeloma is a relapsing remitting cancer with variable periods of remission

Myeloma is treatable with chemotherapy, radiotherapy and targeted novel treatments but is not currently curable

For younger/fitter myeloma patients, treatment includes high-dose therapy and stem cell transplant

Early diagnosis by GP referral is associated with improved overall survival

Patients are living longer; a third of myeloma patients live for 10 years or more

Resources

Patient resources

GP resources

Myeloma Practice Guidelines