Your mother-in-law should discuss the symptoms she is having with her oncologist so that together they can identify its cause. It may be that she has some sites of pain that are related to her arthritis and other sites of pain related to her myeloma. If it isn’t clear what’s causing her pain based on her symptoms and physical examination alone, it may be useful for her to have X-rays or other imaging studies of the painful sites. Your mother-in-law’s doctor most likely wants her to avoid over-the-counter pain relievers that contain acetaminophen, ibuprofen or naproxen because they also suppress fevers, and may thereby mask infections, which are important to recognize as soon as possible. However, there are other pain medications, available by prescription, which can be used to control her symptoms without suppressing fevers. Q2. What stage would a patient be in when bone fractures occur without other causes? My brother is 55 years old, has never been overweight, and with the exception of a couple sports-related injuries in college had been in excellent health most of his life. He was diagnosed with multiple myeloma a couple days ago. His doctors found he has multiple fractures of the spine. There are two staging systems for myeloma. One is called the Durie-Salmon staging system; the other is called the International Staging System (ISS). The Durie-Salmon staging system uses the hemoglobin, calcium, and myeloma protein levels in the blood and urine, as well as the degree of bone involvement by myeloma, to determine stage. By this system, your brother has stage III myeloma because of his multiple vertebral fractures. The International Staging System is a newer staging system, and seems to be a better indicator of prognosis for patients with myeloma. This staging system relies on two blood tests, the albumin and the beta 2 microglobulin. If the albumin is greater than or equal to 3.5, and the beta 2 microglobulin is less than 3.5, this is considered stage I myeloma. If the beta 2 microglobulin exceeds 5.5, this is considered stage III myeloma. Patients who do not meet criteria for stages I or III are considered to have stage II disease. In a study of 10,750 patients with previously untreated symptomatic myeloma, the median survival of patients with stage I disease was 62 months (using the ISS). For those with stage II disease, it was 44 months. And for those with stage III disease, it was 29 months. Please remember that these are median values, and may not reflect your brother’s life expectancy. However, if your brother wishes to know his ISS stage, his oncologist should be able to provide him with the relevant lab results. Please also note that the median is a number similar to but quite different from the “average.” The median is the number, within a series of numbers, at which half the values are above it and half are below it. So if the median number of months of survival were 62 months, then half the people would have a survival greater than 62 months and half less than 62 months. Without more information, there is no way to tell how widely or narrowly the other survival numbers are spread out. Q3. My husband is now 57 days post-stem cell transplant. He is still extremely fatigued and very, very cold. The coldness is disturbing as we live in warm, sunny Florida. He has been in unbearable pain for a year now with lytic lesions on his spine. He is being treated long-distance by a palliative clinic aligned with a major cancer hospital. He has been on oxycodone for a year with little relief, and he still is in tremendous pain. Are there other pain medications that would address his pain? His quality of life and mine is very poor. He cannot sit, so we are unable to leave our home, except for doctor appointments. Significant anemiaand thyroid dysfunction are two possible reasons that your husband may be feeling cold and fatigued. Both can be checked with simple blood tests. If anemia is the cause, it may that his bone marrow needs more time to recover from the effects of the chemotherapy used for the stem cell transplant. In the interim, agents that stimulate the production of red blood cells (for example, Procrit/erythropoeitin or Aranesp/darbepoeitin) and blood transfusions may be used to support his hemoglobin. If an underactive thyroid is the cause of his symptoms, he might need to take an oral synthetic thyroid hormone called levothyroxine (Synthroid, Levoxyl). With regard to your husband’s back pain, it’s possible that he has compression fractures of the vertebrae in his spine, which can happen with myeloma. Procedures such as vertebroplasty or kyphoplasty, where “bone cement” is injected into the collapsed vertebrae, can often provide significant sustained pain relief. Your oncologist should be able to refer you to a physician experienced in doing such procedures. After these procedures have been performed, it is likely that the oxycodone will be sufficient to control whatever back pain he may still feel afterwards. Q4. My husband has been in remission for four years after a full year of treatment that commenced with surgery (for plasmacytoma), radiation, VAD chemo (vincristine, Adriamycin [doxorubicin] and dexamethasone), and autologous stem cell transplant. He is doing well except he experiences hip pain. All his tests are negative. (The plasmacytoma was in T5 vertebrae area. He has no lesions elsewhere.) He receives Zometa (zoledronic acid) every three months. Could the past use of dexamethasone or current Zometa cause hip pain or osteonecrosis? As part of the VAD chemotherapy recipe, your husband did receive a fair amount of dexamethasone. Chronic dexamethasone use is associated with osteonecrosis(bone death) of the hip, which is often painful. I doubt that Zometa is the problem. Also, hip pain is common with aging. Depending on your husband’s age, this is another possibility. To get to the bottom of what’s causing his hip pain, it might be necessary for him to receive X-rays or scans for further assessment and also to meet with an orthopedic specialist. Q5. Six years ago, I was diagnosed with multiple myeloma, and recently I noticed that the bone of my right lower jaw is much thinner than the left side. What would cause the loss of the bone there and not on my left side? There are two possible causes for the jaw asymmetry you describe. First, if the myeloma involved the jaw, the treatment you got for the disease may have killed off the cells which had previously destroyed the bone in that location. With no tissue (bone or cancer) in that location, the jaw may appear “thinned.” Another possibility is related to a side effect of drugs called bisphosphonates. Zometa [zoledronate], the bisphosphonate most commonly used in myeloma to prevent further bone breakdown, is associated with a very rare condition called osteonecrosis of the jaw. Osteonecrosis can be painful and is often related to pre-existing dental problems. Overall, I favor the first explanation in your case, but you should check with your oncologist. Q6. My father has multiple myeloma and just had a hip replacement. He is now refusing to eat. Is this the body’s natural way of shutting down, or is there a way to help increase his appetite? He seems to have given up. He is 84. His blood work has been pretty good. And before he fell, he was doing fine. Your father seems to be depressed. This is very common in older persons, particularly after a hip fracture. The loss of mobility and the sense of losing control over one’s environment can powerfully affect a person’s will to live and therefore his appetite. The first intervention is to address the depression. Involving a geriatric psychiatrist or a geriatrician might be very beneficial for your father. If treatment of depression does not improve your father’s appetite, his doctor could try a variety of different appetite stimulants. Q7. I am 62 years old. I found out I had multiple myeloma about 10 years ago. I did chemo, bone marrow transplant and radiation. The multiple myeloma has been at bay now for seven years. I am in constant pain in my back (where the myeloma originated) and my legs. I cannot get my pain doctor or any other doctor to give me anything strong enough to help. Is this normal? What do you suggest I do? I cannot sleep, have any kind of social life, or work. Unfortunately, many patients with myeloma continue to have some bone pain even after they achieve a remission of their disease, but I am sorry to hear that it is impacting your life so severely. If your pain is caused by a compression fracture of one or more of your vertebrae, you might inquire if a vertebroplasty or kyphoplasty could be done. In these procedures “bone cement” is injected into a vertebra to raise its height and thereby improve some of the alignment of the spine, which can in turn relieve pain. If this is not an option, you might ask your pain management doctor if a nerve block could be done to alleviate the pain. You could also ask whether a transcutaneous electrical nerve stimulator (TENS) unit may be of benefit, since medications do not seem to be helping. Q8. My father has multiple myeloma and has been on dialysis for about two years. I’m concerned about his pain management. Recently, they upped his morphine patch to 150 milligrams because of his acute pain. This caused his blood pressure to drop too low for safe dialysis, however, and they have returned him to 100 milligrams. He is also taking oxycodone and extra-strength Tylenol (acetaminophen) but is still in a lot of pain. He is allergic to aspirin and ibuprofen. What do you do in a case like this? You should see a palliative care or pain specialist. There is no magic formula. The pain medications have to be adjusted to the individual. Learn more in the Everyday Health Multiple Myeloma Center.
