Due to new therapeutic options, patients with newly diagnosed and relapsed multiple myeloma are living longer than they did just one decade ago. Therefore, patients' general health must also be maintained throughout the course of their disease. Proper maintenance of pre-existing or co-morbid conditions can improve quality of life and extend survival.
The following is a description of additional health issues that multiple myeloma patients may face and screening recommendations for each.
Prevalence of Hypertension
According to the American Heart Association, 33% of Americans older than age 18 have been diagnosed with hypertension. Men younger than age 55 have a higher prevalence than women of the same age group, but the prevalence rate evens out for the ages 55-64, and the prevalence rate is higher for women age 65 and older. In addition, the prevalence in African Americans is highest among racial groups at about 41%.
What Is Hypertension?
According the 2017 by the American College of Cardiology/American Heart Association (ACC/AHA), hypertension is determined upon the average of two or more properly measured readings at each of two or more office visits after an initial screening.
Hypertension blood pressure readings show a systolic of 140 mmHg or higher and diastolic of 90 mmHg or higher.
How Is Hypertension Treated?
To prevent hypertension, doctors recommend:
- Weight loss.
- A low-sodium diet.
- Moderation in alcohol consumption.
- Increased physical activity.
Depending on a patient’s comorbid conditions, the treatment of hypertension varies. Multiple myeloma patients who are diagnosed with hypertension should discuss the treatments they require with a cardiovascular specialist.
What Are Screening Recommendations for Hypertension?
The U.S. Preventative Services Task Force recommends to screen blood pressure in adults age 18 and older and following-up on diagnosis after 2 or more elevated readings on separate occasions over a period of one to several weeks. The frequency of screening includes:
- Normal: Recheck in 2 years.
- Prehypertension: Recheck in 1 year.
- Stage I hypertension: Confirm within two months (systolic blood pressure of 140-159 mmHg or diastolic blood pressure of 90-99 mmHg).
- Stage II hypertension: Evaluate or refer to a source of care within one month (systolic blood pressure of 160 mmHg or higher or diastolic blood pressure of 100 mmHg or higher).
- Hypertensive crisis: Evaluate and treat immediately (higher than 180/110 mmHg).
How Do Multiple Myeloma Therapies Affect a Patient’s Blood Pressure?
Multiple myeloma therapies may lead to hypertension or hypotension in patients. For example, dexamethasone use may cause elevated blood pressures due to fluid retention. Also, Velcade® (bortezomib) use may lead to hypotension. Because of the varied side effects of multiple myeloma therapies, patients should have their blood pressure monitored regularly and work with their healthcare team to adjust antihypertensive medications as necessary.
Prevalence of Hyperlipidemia
Of Americans older than age 20, 15% have a total cholesterol level greater than 240 mg/dl, which is considered high risk. Non-modifiable risk factors include age, sex (male), and family history of premature coronary heart disease (CHD). Modifiable risk factors include hypertension, cigarette smoking, diabetes, being overweight or obese, physical inactivity, and an atherogenic diet (National Cholesterol Education Program [NCEP], 2002).
How Is It Diagnosed?
Hyperlipidemia is diagnosed by the results of a fasting lipoprotein profile including total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides.
How Is It Prevented?
To prevent hyperlipidemia, healthcare professionals recommend:
- Weight control
- Dietary modifications
- Regular physical activity
- Smoking prevention or cessation
What Are Screening Recommendations for Hyperlipidemia?
- For men older than age 35, screen for lipid disorder every 5 years if the results are normal.
- For men ages 20-35, screen for lipid disorders only in those with an increased risk for coronary heart disease, and every 5 years if the results are normal.
- For women older than age 20, screen for lipid disorders if they are at increased risk for coronary heart disease.
- The U.S. Preventative Services Task Force makes no recommendations for or against routine screening for lipid disorders in men ages 20-35 or in women ages 20 or older who are not at risk for coronary heart disease.
Multiple myeloma patients should continue to be screened for other malignancies throughout the course of their disease, especially if they have a genetic predisposition to other cancers. Some patients do develop secondary cancers. Proper screening and preventative measures can treat these malignancies should they develop.
How Often Should Patients Be Screened?
The U.S. Preventative Services Task Force recommends a screening mammography with or without clinical breast examination every 1 or 2 years for women age 40 and older.
Learn more about the USPTF's guidelines and recommendations for the screening of breast cancer.
How Often Should Patients Be Screened?
The U.S. Preventative Services Task Force (USPSTF) recommends screenings in women who have been sexually active and have a cervix. Screenings should be initiated at age 21 or at the onset of sexual activity, whichever comes first.
However, the USPSTF recommends against routine screening of women older than age 65 if they have adequate recent screening with normal Pap tests and are not otherwise at high risk, and routine screening for patients with a total hysterectomy for benign disease.
Learn more about the USPTF's guidelines and recommendations for the screening of cervical cancer.
The American Cancer Society recommends the following regarding cervical screenings:
- Begin 3 years after a woman begins having vaginal intercourse, but no later than age 21. Screening must be done annually with conventional Pap tests or every 2 years using liquid-based Pap tests.
- At or after age 30, women who have had 3 normal Pap tests in a row may get screened every 2 or 3 years with cervical cytology, or every 3 years with an HPV DNA test plus cervical cytology.
- Women age 70 or older who have 3 or more normal Pap tests and no abnormal Pap tests in the past 10 years and women who have undergone a total hysterectomy may choose to stop having cervical cancer screenings.
How Often Should Patients Be Screened?
The U.S. Preventative Services Task Force recommends clinicians perform a visual examination to screen for skin cancer. During this exam, they look for moles and other spots that are different in color from the rest of the skin. Clinicians follow the ABCDE rule to look for:
- A = asymmetry (one half of the mole does not match the other half).
- B = border irregularity (edges of the mole are ragged, notched, or blurred).
- C = color (pigmentation of the mole is not uniform, with varying degrees of tan, brown, or black).
- D = diameter of more than ¼ inch (about the size of a pencil eraser).
- E = evolving (the mole is changing over time).
Learn more about the USPSTF's guidelines and recommendations for the screening of skin cancer.
How Often Should Patients Be Screened?
The goal of screening is to reduce the number of people who die from cancer. Getting screened and treated early if cancer is found reduces the risk of dying from colorectal cancer (CRC).
Evidence clearly shows that several different types of screening tests reduce deaths from CRC. These tests include:
- Stool tests: In these screening tests, stool is collected and sent to a lab. The lab can use several different types of tests to check for the presence of blood, which can either be a sign of CRC or of noncancerous growths that can become CRC.
- Colonoscopy: This procedure is done to look inside the rectum and colon for abnormalities. A colonoscope (a thin, tube-like instrument with a light and lens for viewing) is inserted through the rectum into the colon. During this procedure, any abnormal tissue seen may also be sampled and removed. Colonoscopy is also used as a follow-up diagnostic test to look for colon cancer if any of the other tests listed here are found to be positive.
- Flexible sigmoidoscopy: A procedure to look inside the rectum and sigmoid (lower) colon for abnormalities using a sigmoidoscope (a thin, flexible tube) that is inserted into the rectum.
- Flexible sigmoidoscopy combined with stool testing.
- Multi-targeted stool DNA testing: A test of a stool sample that looks for DNA mutations that may indicate the presence of abnormalities. Like other stool tests, it also looks for the presence of hidden blood.
- CT colonography: A procedure that uses a series of X-rays called computed tomography to take a series of pictures of the colon. A computer puts the pictures together to create detailed images that may show abnormalities on the inside surface of the colon.
Learn more about the USPSTF's guidelines and recommendations for the screening of colorectal cancer.
How Often Should Patients Be Screened?
Prostate cancer is the second most common cancer in men in the United States after skin cancer. Older men, African-American men, and men who have a family history of prostate cancer have a greater risk of developing prostate cancer.
Although prostate cancer is very common, in many cases, the cancer does not grow or cause symptoms. If it does grow, it often grows so slowly that it isn’t likely to cause health problems during a man’s lifetime.
Two tests are commonly used to screen for prostate cancer:
- Prostate-specific antigen (PSA) blood test: This test looks for PSA, a substance that may be found in high amounts in men with prostate cancer. However, a high PSA level does not always mean that a man has prostate cancer. PSA levels may be high in men with other types of prostate problems.
- Digital rectal exam: For this test, the doctor inserts a gloved, lubricated finger into the rectum to feel the prostate for lumps or anything else unusual.
The Task Force recommendation primarily focuses on the PSA screening test, with or without the addition of a digital rectal exam or other screening tests.
Learn more about the USPSTF's guidelines and recommendations for the screening of prostate cancer.
Diabetes Mellitus Type 2
How Often Should Patients Be Screened for Type 2 Diabetes?
Screening to determine blood sugar levels can be done with several types of blood tests. One blood test, the A1C test, reflects a person’s average blood sugar levels for the past 2-3 months. Another blood test determines how well a person’s body processes sugar. This test is done after a person drinks a sugar solution. A third type of test— known as fasting blood glucose — can be done after a person has fasted (not had anything to eat or drink except water) for a certain amount of time.
Learn more about the USPSTF's guidelines and recommendations for the screening of Type 2 Diabetes.
*According to study results, patients receiving treatment for multiple myeloma can have an increased incidence of hyperglycemia when dexamethasone is incorporated into their regimen. Although the incidence of diabetes induced by steroid therapy in patients with multiple myeloma is unknown, it might be beneficial to follow the recommendations for hyperglycemia evaluation and management in patients on prolonged steroid therapy.
How Often Should Patients Be Screened for Thyroid Health Issues?
Screening is done with a blood test that measures the amount of TSH in the blood. This test is known as a serum TSH test. Depending on the initial test results, a follow-up test may be needed.
The test can accurately identify a person’s TSH level, but health care professionals do not always agree about what level is “abnormal,” because abnormal levels may be different for different groups. For example, an abnormal level may be different for an older person than for a younger person. Also, abnormal results on a TSH test can be caused by non-thyroid illnesses or medications. Abnormal levels can even return to normal on their own.
Learn more about the USPSTF's guidelines and recommendations for the screening of Thyroid Dysfunction.
*Thalidomide therapy often can lead to subclinical hypothyroidism with normal T3 and T4 levels and slightly elevated TSH levels (Dimopoulos & Eleutherakis-Papaiakovou, 2004). Some hypothesized mechanisms of action include direct thyrotoxicity or the provocation of an immune reaction against the thyroid. Badros et al. (2002) tested those mechanisms in a study that assessed thyroid function in 174 patients with multiple myeloma assigned to receive chemotherapy alone or in combination with thalidomide. The authors of that study found 20% of patients on thalidomide had a serum TSH level greater than 5 uIU/ml 3-4 months after enrollment. The study also evaluated an additional 169 patients with relapsed multiple myeloma who had been treated with thalidomide; 75% of those patients with normal baseline TSH levels had increases in their TSH 2-6 months after starting therapy and 22% had a TSH level greater than 5 uIU/ml. Many of the adverse effects associated with hypothyroidism also may be associated with thalidomide, and include constipation, fatigue, lack of energy, neuropathy, skin rash, and bradycardia.
Both the National Eye Institute and the American Academy of Opthamology websites provide guidelines for routine vision screenings. Multiple myeloma patients with comorbidities, such as diabetes, hypertension, or a family history of ocular disease, may be at greater risk for vision health issues. In addition, patients who are treated with dexamethasone may experience blurred vision or cataract formation.
No screening recommendations currently exist for routine evaluation of hearing. Hearing screening is performed when requested, when conditions occur that increase risk for hearing loss, or when mandated by state or local laws. All hearing screening programs should be conducted under the supervision of an audiologist holding the American Speech-Language-Hearing Association’s (ASHA) Certificate of Clinical Competence.
Adults should be screened at least every 10 years through age 50 and at three-year intervals thereafter (ASHA, 2009). Most patients with multiple myeloma are older adults with a median age at diagnosis between ages 68–70. Education and communication between patients and healthcare providers is crucial. Hearing loss represents a significant barrier to accurate evaluation and management of the disease process in these individuals.
Addiction and Substance Abuse
According to the American Cancer Society, 1 in 10 cancer survivors smoke. The ACS reports, "Not only can smoking cause cancer, but for those already diagnosed, the addictive habit can lead to worse treatment outcomes as well as a poorer health outlook — including getting cancer again." Encouraging smoking cessation is particularly important in patients with multiple myeloma because the pathophysiology of the disease includes a susceptibility to infections, particularly pneumonia. Cigarette smoking and exposure to environmental tobacco smoke increase the risk of pulmonary infections in general and the risk to contract invasive pneumococcal disease by a four-fold factor (Herr et al., 2009). In addition, other pulmonary infections are more frequent in smokers, including influenza and tuberculosis (Herr et al., 2009).
Smokers usually have a lower physical endurance than non-smokers. Smoking decreases lung capacity, whereas exercise increases it. Patients with multiple myeloma are at risk for dyspnea on exertion related to anemia and prior pulmonary infections. Smoking adds an additional burden to the exercise tolerability. Healthcare practitioners caring for patients with MM should screen patients for tobacco use and implement tobacco cessation counseling guidelines.
Alcohol misuse is a major public health problem in the United States. About one-third of the US population is affected by alcohol misuse, with most of these people drinking at the risky or hazardous level.
Alcohol misuse causes more than 85,000 deaths every year, making it the third leading cause of preventable death in the United States. It can play a role in many health problems, including liver disease, high blood pressure, inflammation of the pancreas, certain cancers, problems with mental functioning, and depression. It also contributes significantly to injury and deaths from falls, drowning, fires, motor vehicle crashes, murders, and suicides.
Many types of alcohol screening tests exist. Most people complete a simple questionnaire or answer one or more questions from their health care professional. Screening takes from less than a minute up to 5 minutes.
Counseling to reduce alcohol misuse can be done in various ways, including face-to-face sessions, written self-help materials, computer or Web-based programs, and telephone counseling. During counseling, health care professionals work with patients on various strategies, such as action plans, drinking diaries, stress management, and problem solving.
Learn more about the USPSTF guidelines and recommendations for the screening of Alcohol Misuse.
Immunizations are an important primary prevention that should be continued even when on active treatment for cancer. For most adult patients with multiple myeloma who have received childhood vaccinations, the seasonal influenza vaccine and the pneumococcal vaccine should be administered. Varicella vaccine currently is contraindicated for immunocompromised patients because of immunosuppressive agents such as steroids and other antimyeloma therapy (Marin, Guris, Chaves, Schmid, & Seward, 2007). However, healthcare providers might consider vaccinating family members living with the patient and treating the patients with prophylactic antiviral therapy for a period of time after vaccination. After autologous or allogeneic transplantation, patients should follow the guidelines and recommendations of their transplantation center as well as their healthcare provider.
Influenza vaccine: For the general population, anyone with a medical condition, including those immunocompromised such as patients with multiple myeloma, should receive an annual influenza vaccination. The trivalent inactivated influenza vaccine given via intramuscular (IM) injection is the recommended vaccine for immunocompromised patients. The vaccination should be offered in early autumn, although high-risk patients can still be offered the vaccine after an outbreak is noted in the community. The CDC recommends chemoprophylaxis in individuals at high risk who are vaccinated after influenza activity has begun, those who provide care to high-risk populations, and those who have immune deficiencies (Woolfe, 2008).
Pneumococcal vaccine: Immunocompromised patients with multiple myeloma are at risk for developing pneumococcal disease. Two forms of the vaccination exist: the pneumococcal polysaccharide vaccine and the pneumococcal conjugate vaccine. Those receiving the pneumococcal polysaccharide vaccine include patients age 65 or older (in Alaska, for patients living in certain high-risk areas where an increased rate of invasive disease is noted, it may be recommended for those age 50 or older) and immunocompromised patients age 2 or older. The vaccination can be administered either IM or subcutaneously and should be repeated in five years for those at greatest risk. Severe adverse events are rare with the vaccination.
Tetanus booster: The tetanus booster is recommended every 10 years.
Post-transplantation vaccinations: Patients post-transplantation remain immunocompromised for about 6–12 months and, even after immune reconstitution, they may not have continued immunity to pathogens for which immunizations have previously been given. Antibody titers to vaccine-preventable diseases decline during the 1-4 years after autologous or allogeneic transplantation if not revaccinated (Dykewicz, 2001).
Immunizations such as polio, tetanus toxoid, diphtheria toxoid, pneumococcus, hepatitis B, haemophilus influenzae type B conjugate, and measles, mumps, and rubella, should be initiated per the guidelines and recommendations of the transplantation center at appropriate intervals.
The American Dental Association’s (2009) recommendations for adults for general dental care include brushing teeth twice daily, cleaning between the teeth daily with floss or an interdental cleaner, and seeing the dentist regularly for examinations (including X-rays if warranted) and professional cleaning. Most dental practices and dental insurance companies cite twice yearly visits as the minimum required to maintain good oral hygiene. The risk of osteonecrosis of the jaw associated with the use of IV bisphosphonates and recommendations for prevention, diagnosis, and treatment are discussed in Miceli et al. (2011).
Tobacco use in all forms is the biggest risk factor for oral cancer. Alcohol use combined with tobacco use increases this risk. Patients should be encouraged to avoid tobacco and to limit alcohol use to decrease their risk for oral cancer (USPSTF, 2010). Direct inspection and palpation of the oral cavity is the most commonly recommended method of screening for oral cancer, which can be provided by dentists during routine visits. However, little data exists on the sensitivity and specificity of this method and, although other screening techniques are being evaluated, they are still considered experimental.