Are we Asleep at the Wheel in Diagnosing of Myeloma

Research Article

J Fam Med. 2020; 7(9): 1230.

Are we Asleep at the Wheel in Diagnosing of Myeloma

Ghalehsari N1, Kancharla P1, Nimkar NS1, Mazloom A1, Ashraf F1, Singh A1, Patel E1 and Goldfinger M2*

1Internal Medicine, NewYork Presbyterian Brooklyn Methodist Hospital, USA

2Hematology/Oncology, Montefiore Medical Center, USA

*Corresponding author: Mendel Goldfinger, Hematology/Oncology, Montefiore Medical Center, New York, USA

Received: July 20, 2020; Accepted: November 17, 2020; Published: November 24, 2020

Abstract

Multiple Myeloma (MM) is the abnormal proliferation of plasma cells in the bone marrow often resulting in debilitating symptoms ranging from ostealgia to pathological fractures from bone destruction. According to American Cancer Society, MM accounts for 1-2 % of cancers and approximately 17% of hematological malignancies in the United States each year [1]. Fifty percent of patients with symptomatic MM have three or more primary care visits before they are referred to a specialist, which is greater than any other cancer [2]. It has been shown that a delay in diagnosing multiple myeloma negatively impacts the clinical course of the disease and hence the outcome in patients. Patients with longer diagnostic intervals also experience shorter disease-free survival and more complications from treatment [3]. Early diagnosis of MM has been previously shown to help improve survival rate by timely and effective treatment. We performed a retrospective analysis to determine the average delay in diagnosis of MM from time patients have lab abnormalities related to their disease.

Keywords: Multiple myeloma

Background

Multiple Myeloma (MM) is a plasma cell neoplasm characterized by clonal proliferation of malignant plasma cells resulting in anemia, recurrent infections and renal failure and debilitating symptoms due to bone destruction. MM is the second most common hematological malignancy which accounts for 1-2 % of cancers.

The early symptoms of myeloma are most commonly fatigue and back pain, which are also common for benign conditions and therefore often results in delaying the diagnosis. Over fifty percent of patients with symptomatic MM have three or more primary care visits before they are referred to a specialist, which is greater than any other cancer [3]. In addition, many patients experience symptoms for months before seeking help. What’s more disturbing is that even after seeing a primary care physicians with symptoms related to myeloma, the median time to diagnosis is over 100 days, with 25% of patients waiting longer than 8 month to make the diagnosis resulting in over five months from time of first symptom to date of diagnosis [4].

A delay in diagnosing MM results in severe morbidity, which include end organ damage such as renal failure, life threatening infections, pathological fractures and spinal cord compression. This often results in patients presenting with medical emergencies causing delays in delivering effective therapies. It has been shown that a delay in diagnosing multiple myeloma negatively impacts the clinical course of the disease and hence outcomes [5]. Patients with longer diagnostic intervals also experience shorter disease-free survival and more complications from treatment [1].

Over the past two decades the treatment landscape for MM has been transformed by the introduction of novel agents, which include immunomodulatory drugs, proteasome inhibitors and monoclonal antibodies; which have resulted in a steady improvement in survival [6]. There has also been emerging evidence demonstrating a benefit to treating patients at an earlier phase of the disease, which is known as smoldering myeloma [7]. With more effective therapies and a shift in paradigm to earlier treatment, it’s now more important than ever to not to delay the diagnosis of MM. Herein, we evaluated the time delay in diagnosis from when physicians first have evidence of lab abnormalities suggesting a diagnosis of MM.

Methods

This is a retrospective electronic chart review of all indexed newly diagnosed MM cases between 1/1/2014 through 12/31/2018 on bone marrow biopsy done at New York-Presbyterian Brooklyn Methodist Hospital (NYP BMH). NYP BMH is a Weill Cornell Medical College-affiliated hospital in Brooklyn, NY whose patient population includes privately insured, uninsured and Medicare/Medicaid. Data abstraction from the Electronic Medical Record (EMR) was uniform and involved baseline characteristics including age, gender and race. International Classification of Diseases (ICD)-10-CM code (C90.00) was used for extraction of data which identified 492 patients.

313 patient charts were reviewed and patients with MGUS or a prior diagnosis of multiple myeloma were excluded, leaving a total of 104 patients in the final study who were newly diagnosed with MM at NYP-BMH. The hospital EMR was utilized to collect pertinent labs on these patients. These patients either were discharged from the emergency room or were admitted.

The Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) recorded on the EMR before and at the time of diagnosis were reviewed. We calculated the number of days between the dates of the first abnormal laboratory value seen on bloodwork for a myeloma related sign (at least 90 days prior to diagnosis) to the date of bone marrow biopsy that confirmed the diagnosis. The inclusion criteria included anemia defined as hemoglobin <12gm/dl, hypercalcemia defined by corrected calcium >10, kidney dysfunction with a creatinine >1.5 and total protein >8. Cytogenetic characteristics of patients diagnosed with MM were also reviewed.