Diagnosis and staging

Tests that are always indicated include:

Blood and urine tests to assess for myeloma and myeloma-defining events:

• full blood count, differential and blood film
• urea and electrolytes, calcium, phosphate, magnesium, urate
• liver function test, albumin
• beta-2 microglobulin, LDH, C-reactive protein
• serum protein electrophoresis and immunofixation
• serum free light chain
• 24-hour urine collection: protein excretion, creatinine clearance, Bence Jones protein.

Bone marrow aspirate and trephine with morphology, immunohistochemistry, cytogenetics, FISH and flow cytometry.

Other tests to look for end-organ damage include a whole-body low-dose CT skeletal survey and, in selected cases, whole-body or whole-spine and pelvis MRI or PET-CT.

The Revised International Staging System (R-ISS) staging criteria for MM is based on: beta-2 microglobulin, albumin, LDH and cytogenetics/FISH assessment.

Treatment planning

The multidisciplinary team should ideally discuss all newly diagnosed patients with multiple myeloma prior to treatment implementation.

In some cases, treatment may be required sooner.

Research and clinical trials

See the OCP resources appendix and relevant steps for a list of clinical trial resources relevant to MM.

Communication

The lead clinician’s¹ responsibilities include:

• discussing a timeframe for diagnosis and treatment options with the patient and/or carer
• explaining the role of the multidisciplinary team in treatment planning and ongoing care
• encouraging discussion about the diagnosis, prognosis, advance care planning and palliative care while clarifying the patient’s wishes, needs, beliefs
• and expectations, and their ability to comprehend the communication
• providing appropriate information and referral to support services as required
• communicating with the patient’s GP about the diagnosis, treatment plan and recommendations from multidisciplinary meetings.

Checklist

• Diagnosis has been confirmed
• Performance status and comorbidities assessed
• Patient discussed at multidisciplinary meeting and decisions provided to the patient and/or carer
• Clinical trial enrolment considered
• Supportive care needs assessed and referrals to allied health services actioned as required
• Referral to support services (such as Cancer Council, Leukaemia Foundation, Myeloma Australia)
• Treatment costs discussed with the patient and/or carer

Timeframe

Investigations should be completed within 2 weeks of the first consult, or sooner depending on clinical urgency.

Prospective review at a multi- disciplinary meeting should ideally occur for all cases.

1 Lead clinician – the clinician who is responsible for managing patient care. The lead clinician may change over time depending on the stage of the care pathway and where care is being provided.