A Guide to Multiple Myeloma Bone Disease

Multiple myeloma (MM) is a cancer of the plasma cells. This medical condition causes an individual's bones to progressively break down. The cancerous plasma cells significantly impact bone balance, leading to bone disease in multiple myeloma (MM), also known as myeloma bone disease (MBD). Approximately 85% of myeloma patients (https://pmc.ncbi.nlm.nih.gov/articles/PMC12249160/)develop significant complications like bone disease, often causing significant pain and mobility issues.

When facing multiple myeloma, bone health quickly becomes one of the most important concerns for patients and their care partners. If you or a loved one has been diagnosed with multiple myeloma (https://www.myeloma.org/newly-diagnosed/do-you-have-myeloma), it's essential to understand how this cancer can affect the bones and learn strategies to protect bone health.

Why Myeloma Affects the Bones

In most individuals, bones constantly renew and regrow through a process called bone remodeling (https://books.byui.edu/bio_381_pathophysiol/__1011__mechanisms_o). Two types of cells manage this process:

• Osteoclasts: Cells that break down old bone tissue.
• Osteoblasts: Cells that build new bone.
   

Multiple myeloma bone disease occurs when cancer cells disrupt this balanced cycle by activating bone-destroying osteoclasts and inhibiting bone-building osteoblasts. As a result, the bones break down faster, and there is less new bone to replace them.

Bone disease can cause bones to become thinner and weaker, known as osteoporosis. It can also create osteolytic lesions, or weak spots and holes in the bone. The weakened bone is more likely to break due to minor pressures or fractures, even during normal daily activities. The bones most commonly affected (https://www.academia.edu/105708732/Severe_Spine_Cord_Compression_By_Plasmacytoma_Multiple_Myeloma_Series_of_Cases) are the upper ends of the long bones of the arms and legs, as well as the axial skeleton, including:

• Spine
• Pelvis
• Ribs
• Skull

Common Symptoms and Complications 

It's important to note that myeloma can result in a range of medical conditions (https://www.myeloma.org/multiple-myeloma-complications) that affect the kidneys, blood, and immune system. However, the bones are affected the most often. Bone complications of multiple myeloma can manifest in several ways, including:

• Bone pain: Myeloma cells typically accumulate in the back, hips, and ribs. These are common areas for patients to report pain, especially with movement and at night.
• Spinal cord compression: Myeloma masses that grow near the spine can cause vertebrae to collapse, pressing against the spinal cord. This complication can cause numbness, muscle weakness, severe back pain, or difficulty controlling the bladder. It requires immediate medical attention.
• Fractures: Any of the affected bones can fracture easily, but vertebral compression fractures are common.
• Hypercalcemia: As bones deteriorate, calcium can leak into the bloodstream and lead to high blood calcium levels (https://www.ncbi.nlm.nih.gov/books/NBK430714/). Hypercalcemia is associated with symptoms like confusion, frequent urination, thirst, and fatigue. 
   

Recognizing these symptoms is key to early intervention and improving quality of life. 

How Doctors Diagnose Myeloma Bone Disease

Myeloma bone lesions can be difficult to detect in the early stages. Some patients may be diagnosed with smoldering multiple myeloma (SMM), an asymptomatic blood and bone marrow disorder that can progress to active myeloma. Fortunately, your doctor can use the international staging system (ISS) (https://www.myeloma.org/international-staging-system-iss-reivised-iss-r-iss) and revised ISS (R-ISS) to classify the disease. Healthcare professionals can also perform standard diagnostic imaging tests to help stage the disease and plan appropriate treatment strategies. For example:

• X-rays: X-rays are one of the first tests performed to find fractures and advanced lesions, but they may not be as effective at detection until a significant amount of the bone has been lost.
• MRI: Magnetic resonance imaging (MRI) provides detailed images of bone marrow infiltration by myeloma cells before visible bone destruction occurs.
• CT/PET: Computed tomography (CT) and positron emission tomography (PET) offer more detailed, cross-sectional images that can detect small lesions and bone damage earlier than X-rays. PET/CT scans can also help distinguish between active and inactive disease.

Medical Treatments to Protect Your Bones 

Addressing bone disease is key to treating multiple myeloma. Most patients use a combination of medical treatments (https://www.myeloma.org/multiple-myeloma-treatment) to protect and strengthen the affected bones, such as:

• Bone-strengthening drugs: Medications like Zometa® and Aredia® (bisphosphonates) can help slow down bone destruction by inhibiting osteoclast activity. However, these medications have potential side effects on your overall kidney health and can lead to osteonecrosis of the jaw (ONJ). The FDA approved Xgeva® (https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/125320s094lbl.pdf) (denosumab) in 2018 for the treatment of myeloma bone disease. According to guidelines from the American Society of Clinical Oncology (ASCO), Xgeva® may be preferable to bisphosphonates in patients with kidney damage.
• Anti-myeloma therapies: Treating the underlying cancer can help reduce bone-damaging effects. Some anti-myeloma therapies include stem cell transplants, monoclonal antibodies, proteasome inhibitors, and immunomodulatory drugs.
• Other interventions: Your healthcare team may recommend radiation therapy to help kill myeloma cells and address localized pain. Surgical procedures like kyphoplasty or vertebroplasty can stabilize the spine or repair fractures. 

Practical Ways to Support Your Bone Health

While cure-driven research is underway, there are plenty of other things you can do to improve myeloma bone health in the meantime:

• Nutrition and supplements: A balanced diet rich in vitamin D and calcium can help support good bone health. Try to incorporate leafy greens, dairy products, and whole foods into your diet. Be sure to consult with your healthcare provider before adjusting your calcium intake or taking new supplements.
• Safe physical activity: Low-impact activities like swimming or walking can help preserve bone density and muscle strength. A physical therapist can help develop an appropriate exercise program tailored to your needs.
• Fall prevention: You can reduce your risk of fractures and injuries by adding modifications in your home, such as installing grab bars in bathrooms, ensuring good lighting, using assistive walking devices, and removing tripping hazards like loose rugs and clutter.
• Tips for care partners: Your loved ones can help support your bone health by offering emotional support, (https://www.myeloma.org/caregivers-or-care-partners-myeloma-patients) monitoring for new symptoms, assisting with home safety modifications, and attending medical appointments to communicate changes and understand treatment plans.

Finding Answers and Support

Living with myeloma bone disease can be challenging, but treatment options continue to improve. At the International Myeloma Foundation, we understand the value of improving outcomes and quality of life for patients.

If you're looking for more answers regarding bone disease caused by myeloma, we encourage you to reach out to one of our specialists. Contact the International Myeloma Foundation's InfoLine online, (https://www.myeloma.org/infoline) or call us directly at 1-800-452-CURE (2873). Our team is here to provide confidential support for patients and their families.

Be sure to read the IMF publications Understanding Treatment of Myeloma Bone Disease (https://www.myeloma.org/resource-library/understanding-treatment-myeloma-bone-disease) and Understanding Treatment of Myeloma-Induced Vertebral Compression Fractures (https://www.myeloma.org/resource-library/understanding-treatment-myeloma-induced-vertebral-compression-fractures) listed under Related Content on this page.