Signs and symptoms to investigate

MM can present with many otherwise unexplained, non-specific symptoms and/ or blood test abnormalities, as well as end-organ complications or related organ tissue injury.

End-organ complications that are often associated with MM include: bone loss, renal failure, hypercalcaemia, immune suppression or anaemia.

Signs and symptoms include:

• fatigue and general weakness
• bone pain or a broken bone with minimal trauma
• frequent infections
• unintentional weight loss
• symptoms of hypercalcaemia including mental fogginess or confusion, new- onset constipation or abdominal pain and increased thirst
• new-onset back pain, particularly with neurological symptoms such as leg weakness, loss of bladder or bowel control, or loss of sensation
• hyperviscosity (easy bruising, bleeding gums, cloudy vision), but this is rare.

Blood test abnormalities that may suggest MM include:

• anaemia
• high levels of creatinine
• hypercalcaemia
• elevated ESR without a known infection or inflammation
• increase protein–albumin gap without an infection or inflammation
• a paraprotein on serum protein electrophoresis
• elevated serum kappa or lambda light chains with an abnormal kappa–lambda light chain ratio.

Initial Investigations
If there is high suspicion of MM after clinical assessment, the GP should promptly refer the patient to a haematologist or specialist centre to confirm the diagnosis.

In cases where clinical suspicion is lower, preliminary investigations include the following:

• blood test to identify paraproteins or elevated free light chains that may indicate underlying MM
• blood and urine tests that may indicate end-organ dysfunction
• x-ray or CT imaging of painful areas to assess for fractures, lytic lesions and/or soft tissue plasmacytomas.

Referral options

At the referral stage, the patient’s GP or other referring doctor should advise the patient about their options for referral, waiting periods, expertise, potential out- of-pocket costs and the range of services available. This will enable patients to make an informed choice of specialist and health service.

Communication

The GP’s responsibilities include:

• explaining to the patient, family and/or carer who they are being referred to and why
• informing the patient, family and/or carer that they can contact Cancer Council, Leukaemia Foundation and Myeloma Australia.

Checklist

• Signs and symptoms recorded
• Investigations completed
• Supportive care needs assessed, and referrals to allied health services actioned as required
• Patient notified of support services such as Cancer Council 13 11 20, Leukaemia Foundation 1800 620 420 and Myeloma Australia 1800 693 566
• Referral options discussed with the patient and/or carer including cost implications

Timeframe

Presenting symptoms should be promptly assessed. If moderate or severe symptoms are identified, the GP should review promptly (within 2 days) to avoid missing a medical emergency.

In non-urgent cases the GP should have results, review the patient and finalise a path of action within 4 weeks.

Patients with a paraprotein and/ or elevated light chain and end- organ damage should be seen by a specialist as soon as possible, ideally not more than 1 week.

If there is no end-organ damage, a specialist consult should occur within 4 weeks.