Optimal timeframes & summary
Evidence-based guidelines, where they exist, should inform timeframes. Treatment teams need to recognise that shorter timeframes for appropriate consultations and treatment can promote a better experience for patients. Three steps in the pathway specify timeframes for care (Figure 3). They are designed to help patients understand the timeframes in which they can expect to be assessed and treated, and to help health services plan care delivery in accordance with expert-informed time parameters to meet the expectation of patients. These timeframes are based on expert advice from the Multiple Myeloma Working Group.
Timeframes for care for multiple myeloma.
| Step in pathway | Care point | Timeframe |
| Presentation, initial investigations and referral | Signs and symptoms | Presenting symptoms should be promptly clinically assessed. |
| Initial investigations initiated by GP | Patients with moderate or severe symptoms with a differential of MM should be reviewed within 2 days. In non-urgent cases, investigations/treatment should be finalised and a path of action decided within 4 weeks | |
| Referral to specialist | Patients with a paraprotein and/or elevated light chain and end-organ damage should be seen by a specialist ASAP, not more than 1 week. If there is no end-organ damage, specialist consult should occur within 4 weeks. | |
| Diagnosis, staging and treatment planning | Diagnosis and staging | Specialist diagnostic work-up should be complete within 2 weeks of first consult, or sooner depending on clinical urgency. |
| Multidisciplinary team meeting and treatment planning | Ideally, a multidisciplinary discussion is conducted before treatment implementation. In some cases, treatment may be required sooner. | |
| Treatment | Systemic therapy | Treatment should ideally begin within 2 weeks of confirmed diagnosis, or within 24 hours if there is critical organ compromise or rapid clinical progression. |
| Radiation therapy | Where possible, radiotherapy should begin within 24 hours of referral if there is critical organ compromise, or within 48 hours of referral if the intent is local pain control. The maximum acceptable waiting period is 48 hours for critical organ compromise and 14 days for pain control. For solitary bone plasmacytoma or extramedullary plasmacytoma where the treatment goal is curative, radiotherapy should start within 14 days of referral where possible, with a maximum acceptable waiting time of 28 days. |
Seven steps of the optimal care pathway
Step 1: Prevention and early detection
Step 2: Presentation, initial investigations and referral step
Step 3: Diagnosis, staging and treatment planning
Step 4: Treatment
Step 5: Care after initial treatment and recovery
Step 6: Managing refractory, relapsed, residual or progressive disease
Step 7: End-of-life care
This pathway covers Multiple myeloma (mm).
MM is a plasma cell neoplasm and the second most common haematological malignancy (Kazandjian 2016).
Two phases of disease precede MM:
- Monoclonal gammopathy of uncertain significance (MGUS): An initial premalignant phase with no evidence of myeloma on bone marrow biopsy. Nearly everyone who develops active MM first experiences MGUS. The average risk of someone with MGUS developing MM is about 1 per cent per year (Quach & Prince 2019).
- Smouldering myeloma (previously called asymptomatic myeloma): In this phase there is evidence of myeloma within the bone marrow, but further work-up shows no evidence of myeloma-defining events.
This pathway covers solitary plasmacytoma and MM with myeloma-defining events that warrant treatment:
- Multiple myeloma (previously called symptomatic myeloma): A cancer of plasma cells where there is evidence of myeloma-defining events that require anti-myeloma
- Solitary plasmacytoma: This refers to a single site of biopsy-proven bone or soft tissue clonal plasma cells with normal bone marrow assessment, normal skeletal survey and magnetic resonance imaging (MRI), and absence of end-organ damage or amyloidosis that can be attributed to the clonal plasma cells.
The yearly incidence rate of MM in Australian adults is 7.6 cases per 100,000, with a five-year relative survival of 53.8 per cent. MM has a male predominance at 9.2 cases per 100,000 compared with 6.2 cases per 100,000 in females. The median age of diagnosis in Australia is 72.6 years, with 83 per cent of patients diagnosed aged 60 or older (AIHW 2021).
The yearly incidence rate of MM in Australian adults was estimated to be 7.6 cases per 100,000, with a five-year relative survival of 53.8 per cent. MM has a male predominance at 9.2 cases per 100,000 compared with 6.2 cases per 100,000 in females. The median age of diagnosis in Australia was estimated to be 72.6 years, with 83 per cent of patients diagnosed aged 60 or older (AIHW 2021).
