STEP 3: Diagnosis, staging, and treatment planning

Step 3 outlines the process for confirming the diagnosis and stage of cancer and for planning subsequent treatment. The guiding principle is that interaction between appropriate multidisciplinary team members should determine the treatment plan.

The treating team, after taking a thorough medical history and making a thorough examination

of the patient, should undertake the following investigations under the guidance of a haematologist.

Tests that are always indicated

Blood and urine tests to assess for MM and MM- 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: CD138
    • cytogenetic assessment (success rate of cytogenetic assessment falls at lower levels of marrow plasmacytosis e.g. < 15%)
    • FISH, the minimum requested panel should include: t(4;14), t(14;16), t(11;14), 17p del, 1q21 amplification
    • flow cytometry with the following minimal panel: CD138, CD19, CD56, kappa and lambda light chain expression.

Whole-body low-dose CT skeletal survey

Whole-body low-dose CT skeletal survey is recommended as the first-line imagery in all MM cases (both suspected and confirmed). It is more sensitive than an x-ray skeletal survey at detecting bone lytic lesions, and recent improvements in CT technology mean that the effective radiation doses are now similar to x-ray (Hillengass et al. 2019).

Tests that are indicated in selected cases

  • Whole body (if not whole spine and pelvis) MRI
  • To assess for MM lesions in patients with a histological diagnosis of MM but negative or inconclusive CT skeletal survey
  • To confirm suspected spinal cord compression, nerve impingement or paraspinal soft tissue plasmacytoma in patients with back pain
  • PET-CT

– Is particularly useful for patients with extramedullary disease or oligo/non-secretory myeloma

  • Bone densitometry

– When osteoporosis is suspected

  • Image-guided biopsy of the affected bone or soft tissue area

– Use if bone marrow aspirate and trephine shows less than 5 per cent of clonal plasma cells

If MM is suspected, diagnostic and staging investigations should be complete within two weeks of the first consult by the haematologist or specialist treating centre, or sooner depending on clinical urgency.

Staging and prognostic assessment are critical elements in treatment planning and should be clearly documented in the patient’s medical record. The burden of disease at baseline, including the degree of bone marrow involvement, any evidence of end-organ damage and prognostic parameters, should be clearly documented in the patient’s medical record.

The most widely accepted prognostic model for MM is the Revised International Staging System (R-ISS). This incorporates the presence of high-risk genetic lesions based on cytogenetics and/or FISH, and the level of beta-2 microglobulin, albumin and LDH (IMF 2019).

More information

For more information visit the Myeloma Australia website .

Performance status is a central factor in the care of MM, and should be clearly documented in the patient’s medical record.

Performance status should be measured and recorded using an established scale such as the Karnofsky scale or the Eastern Cooperative Oncology Group (ECOG) scale.

It is also important to evaluate and document comorbidities involving major organ systems (e.g. renal, cardiac, respiratory), overall functional status and physiological robustness because these may impact on treatment strategies. These issues are particularly important in the geriatric context of MM, given that the median age of diagnosis is over 70 years old (Quach & Prince 2019). There are many well established geriatric assessment tools that incorporate comorbidities, patient performance status, frailty and vulnerability. For MM, the most widely used is the IMWG geriatric assessment tool (Engelhard 2016).

These provide individualised frailty scores that are useful to minimise adverse events when choosing a therapy (refer to the online myeloma frailty score calculator <>).

A number of factors should be considered at this stage:

  • the patient’s overall condition, life expectancy, personal preferences and decision-making capacity
  • discussing the multidisciplinary team approach to care with the patient
  • appropriate and timely referral to an MDM
  • pregnancy and fertility
  • support with travel and accommodation
  • teleconferencing or videoconferencing as

The multidisciplinary team should meet to discuss newly diagnosed patients before definitive treatment so that a treatment plan can be recommended and there can be early preparation for the post-treatment phase. The level of discussion may vary, depending on the patient’s clinical and supportive care factors. If patients are not discussed at an MDM, they should at least be named on the agenda for noting. The proposed treatment must be recorded in the patient’s medical record and should be recorded in an MDM database where one exists.

Teams may agree on standard treatment protocols for non-complex care, facilitating patient review (by exception) and associated data capture.

Results of all relevant tests and access to images should be available for the MDM. Information about the patient’s concerns, preferences and social and cultural circumstances should also be available.

The multidisciplinary team requires administrative support in developing the agenda for the meeting, for collating patient information and to ensure appropriate expertise around the table to create an effective treatment plan for the patient. The MDM has a chair and multiple lead clinicians. Each patient case will be presented by a lead clinician (usually someone who has seen the patient before the MDM). In public hospital settings, the registrar or clinical fellow may take this role. A member of the team records the outcomes of the discussion and treatment plan in the patient history and ensures these details are communicated to the patient’s general practitioner. The team should consider the patient’s values, beliefs and cultural needs as appropriate to ensure the treatment plan is in line with these.

The multidisciplinary team should be composed of the core disciplines that are integral to providing good care. Team membership should reflect both clinical and supportive care aspects of care.

Pathology and radiology expertise are essential.

See Appendix E for a list of team members who may be included in the multidisciplinary team for MM.

Core members of the multidisciplinary team are expected to attend most MDMs either in person or remotely via virtual mechanisms. Additional expertise or specialist services may be required for some patients. An Aboriginal and Torres Strait Islander cultural expert should be considered for all patients who identify as Aboriginal or Torres Strait Islander.

The general practitioner who made the referral is responsible for the patient until care is passed to another practitioner who is directly involved in planning the patient’s care.

The general practitioner may play a number of roles in all stages of the cancer pathway including diagnosis, referral, treatment, shared follow-up care, post-treatment surveillance, coordination and continuity of care, as well as managing existing health issues and providing information and support to the patient, their family and carer.

A nominated contact person from the multidisciplinary team may be assigned responsibility for coordinating care in this phase. Care coordinators are responsible for ensuring there is continuity throughout the care process and coordination of all necessary care for a particular phase (COSA 2015). The care coordinator may change over the course of the pathway.

The lead clinician is responsible for overseeing the activity of the team and for implementing treatment within the multidisciplinary setting.

Participation in clinical trials, patient registries and tissue banking, where available, is encouraged for patients with MM. Cross-referral between clinical trials centres should be encouraged to facilitate participation.

For more information visit:

Cancer prehabilitation uses a multidisciplinary approach combining exercise, nutrition and psychological strategies to prepare patients for the challenges of cancer treatment such as systemic therapy or radiation therapy. Team members may include haematologists, clinical psychologists, exercise physiologists, physiotherapists and dietitians, among others.

Patient performance status is a central factor in cancer care and should be frequently assessed. All patients should be screened for malnutrition using a validated tool, such as the Malnutrition Screening Tool (MST). The lead clinician may refer obese or malnourished patients to a dietitian preoperatively or before other treatments begin.

Patients who currently smoke should be encouraged to stop smoking before receiving treatment. This should include an offer of referral to Quitline in addition to smoking cessation pharmacotherapy, if clinically appropriate.

Evidence indicates that patients who respond well to prehabilitation may have fewer complications after treatment. For example, those who were exercising before diagnosis and patients who use prehabilitation before starting treatment may improve their physical or psychological outcomes, or both, and this helps patients to function at a higher level throughout their cancer treatment (Cormie et al. 2017; Silver 2015).

For patients with MM, the multidisciplinary team should consider these specific prehabilitation assessments and interventions for treatment-related complications or major side effects:

  • conducting a physical and psychological assessment to establish a baseline function level
  • identifying impairments and providing targeted interventions to improve the patient’s function level (Silver & Baima 2013)
  • reviewing the patient’s medication to ensure optimisation and to improve adherence to medicine used for comorbid conditions.

Following completion of primary cancer treatment, rehabilitation programs have considerable potential to enhance physical function.

Cancer and cancer treatment may cause fertility problems. This will depend on the age of the patient, the type of cancer and the treatment received. Infertility can range from difficulty having a child to the inability to have a child. Infertility after treatment may be temporary, lasting months to years, or permanent (AYA Cancer Fertility Preservation Guidance Working Group 2014).

Although MM usually occurs in elderly patients, around 2 per cent of patients are diagnosed below the age of 40 years. Patients of child-bearing potential need to be advised, and potentially referred, for a discussion about fertility preservation before starting treatment and need advice about contraception before, during and after treatment. Effective contraception is particularly important for those taking immunomodulators (IMiDs) such as thalidomide, lenalidomide and pomalidomide because these can cause serious birth defects and abnormalities to the fetus. Males should not conceive or donate sperm while taking IMiDs, and women should not become pregnant while taking them.

Patients and their family should be aware of the ongoing costs involved in optimising fertility. Fertility management may apply in both men and women. Fertility preservation options are different for men and women and the need for ongoing contraception applies to both men and women.

The potential for impaired fertility should be discussed and reinforced at different time points as appropriate throughout the diagnosis, treatment, surveillance and survivorship phases of care. These ongoing discussions will enable the patient and, if applicable, the family to make informed decisions. All discussions should be documented in the patient’s medical record.

More information

See the Cancer Council website  for more information.

See validated screening tools mentioned in Principle 4 ‘Supportive care’.

A number of specific challenges and needs may arise for patients at this time:

  • assistance for dealing with psychological and emotional distress while adjusting to the diagnosis; treatment phobias; existential concerns; stress; difficulties making treatment decisions; anxiety or depression or both; psychosexual issues such as potential loss of fertility and premature menopause; history of sexual abuse; and interpersonal problems
  • management of physical symptoms such as pain and fatigue (Australian Adult Cancer Pain Management Guideline Working Party 2019)
  • malnutrition or undernutrition, identified using a validated nutrition screening tool such as the MST (note that many patients with a high BMI [obese patients] may also be malnourished [WHO 2018])
  • support for families or carers who are distressed with the patient’s cancer diagnosis
  • support for families/relatives who may be distressed after learning of a genetically linked cancer diagnosis
  • specific spiritual needs that may benefit from the involvement of pastoral/spiritual care. Additionally, palliative care may be required at this

For more information on supportive care and needs that may arise for different population groups, see Appendices A, B and C.

In discussion with the patient, the lead clinician should undertake the following:

  • establish if the patient has a regular or preferred general practitioner and if the patient does not have one, then encourage them to find one
  • provide written information appropriate to the health literacy of the patient about the diagnosis and treatment to the patient and carer and refer the patient to the Guide to best cancer care (consumer optimal care pathway) for MM, as well as to relevant websites and support groups as appropriate such as the Cancer Council , Leukaemia Foundation and Myeloma Australia 
  • provide a treatment care plan including contact details for the treating team and information on when to call the hospital
  • discuss a timeframe for diagnosis and treatment with the patient and carer
  • discuss the benefits of multidisciplinary care and gain the patient’s consent before presenting their case at an MDM
  • provide brief advice and refer to Quitline (13 7848) for behavioural intervention if the patient currently smokes (or has recently quit), and prescribe smoking cessation pharmacotherapy, if clinically appropriate
  • recommend an ‘integrated approach’ throughout treatment regarding nutrition, exercise and minimal or no alcohol consumption among other considerations
  • communicate the benefits of continued engagement with primary care during treatment for managing comorbid disease, health promotion, care coordination and holistic care
  • where appropriate, review fertility needs with the patient and refer for specialist fertility management (including fertility preservation, contraception, management during pregnancy and of future pregnancies)
  • be open to and encourage discussion about the diagnosis, prognosis (if the patient wishes to know) and survivorship and palliative care while clarifying the patient’s preferences and needs, personal and cultural beliefs and expectations, and their ability to comprehend the communication
  • encourage the patient to participate in advance care planning including considering appointing one or more substitute decision-makers and completing an advance care directive to clearly document their treatment Each state and territory has different terminology and legislation surrounding advance care directives and substitute decision-makers.

The lead clinician has these communication responsibilities:

  • involving the general practitioner from the point of diagnosis
  • ensuring regular and timely communication with the general practitioner about the diagnosis, treatment plan and recommendations from MDMs
  • supporting the role of general practice both during and after treatment
  • discussing shared or team care arrangements with general practitioners or regional cancer specialists, or both, together with the patient.

More information

Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.