Palliative Care Considerations for Initial Visit with Stage 3 Multiple Myeloma
At the initial palliative care visit for a patient with stage 3 multiple myeloma, prioritize comprehensive pain assessment and bone disease management, as pain affects 72% of patients and skeletal complications are the primary driver of morbidity in this population. 1, 2
Symptom Assessment and Burden
Pain Evaluation
- Assess pain severity using a numerical visual scale (0-10) for both worst and average pain, as moderate-to-severe pain (≥5/10) is present in 57% of patients at baseline 2
- Evaluate pain interference with general activity, sleep, and mood specifically, as these functional domains are significantly impacted in 48% of patients 2
- Identify pain etiology: bone lesions (lytic lesions, pathologic fractures, vertebral compression fractures), neuropathy from treatment, or disease-related complications 3
- Consider that stage 3 disease is defined by hemoglobin <8.5 g/dL, calcium >3.0 mmol/L, advanced bone lesions, and high M-protein levels, all contributing to symptom burden 3
Comprehensive Symptom Screening
- Screen for the following symptoms systematically, as patients report an average of 7.2 symptoms out of 15 potential symptoms 1:
- Calculate physical and emotional symptom burden scores to track response to interventions 2
Bone Disease Management
Bisphosphonate Therapy
- Initiate long-term bisphosphonate therapy immediately, as this reduces skeletal-related events in stage III disease 3, 4
- Zoledronic acid is the preferred agent for hypercalcemia and bone disease management 5, 6
- Ensure calcium (500 mg daily) and vitamin D (400 IU daily) supplementation for all patients receiving bisphosphonates to prevent hypocalcemia 5, 6
- Perform baseline dental examination before initiating bisphosphonates to assess osteonecrosis of the jaw (ONJ) risk 5, 6
Monitoring Requirements
- Measure creatinine clearance, serum electrolytes, and urinary albumin before and during bisphosphonate therapy, as stage 3B disease (creatinine ≥177 μmol/L) requires dose adjustments 3, 5
- For creatinine clearance 30-60 mL/min, use reduced zoledronic acid doses; avoid pamidronate and zoledronic acid if <30 mL/min 5
Functional and Psychosocial Assessment
Performance Status and Frailty
- Assess functional status, comorbidities, and frailty, as these determine treatment intensity and prognosis 3
- Evaluate ability to perform activities of daily living, as physical function is strongly associated with overall palliative care concerns 1
Psychological Distress
- Screen for anxiety and depression systematically, as younger age and advanced disease stage are associated with higher psychological burden 1
- Address existential concerns, as the median survival for stage 3 disease is 5-7 years, creating long-term uncertainty 7
Disease-Specific Complications
Hypercalcemia Management
- Provide aggressive hydration as first-line treatment for hypercalcemia (calcium >3.0 mmol/L in stage 3) 5
- Monitor for hypercalcemia symptoms: polyuria, gastrointestinal disturbances, dehydration, decreased glomerular filtration rate 5
Renal Insufficiency
- Evaluate renal function through creatinine clearance, as stage 3B disease (creatinine ≥177 μmol/L) affects treatment options 3
- Monitor for renal impairment progression, as both disease and bisphosphonates can worsen kidney function 5
Anemia
- Address anemia (hemoglobin <8.5 g/dL in stage 3), which contributes significantly to fatigue and reduced quality of life 3, 1
Spinal Cord Compression
- Assess for neurologic symptoms requiring urgent intervention with high-dose dexamethasone, surgical decompression if due to bone fragments, and local radiotherapy 8
Radiotherapy Considerations
- For painful osteolytic lesions, consider radiotherapy (30 Gy in 10-15 fractions) 5
- Consider balloon kyphoplasty for painful vertebral compression fractures 5
- Systemic anti-myeloma therapy should not be delayed for radiation; they can be given concurrently with careful toxicity monitoring 5
Prognostic Discussion
Risk Stratification
- Review International Staging System (ISS) classification: stage 3 is defined by β2-microglobulin >5.5 mg/L, indicating poor prognosis 3, 4
- Discuss cytogenetic risk factors if available (del(17p), t(4;14), t(14;16)), as these affect treatment decisions and prognosis 3, 4
Goals of Care
- Frame the discussion around multiple myeloma being incurable but increasingly manageable as a chronic disease 7, 9
- Discuss the long disease trajectory (median 5-7 years for newly diagnosed stage 3) and the role of palliative care throughout this continuum 7
Follow-Up Planning
Symptom Monitoring Schedule
- Schedule follow-up palliative care consultations at regular intervals, as early palliative care improves pain control and reduces symptom burden 2
- In the study demonstrating feasibility of early palliative care, 86.6% of patients remained alive and attending the palliative care clinic, with significant improvements in pain and mood 2
Coordination with Oncology
- Establish clear communication with the hematology team regarding M-protein monitoring (serum/urine electrophoresis) and disease response 4, 8
- Coordinate timing of palliative interventions with anti-myeloma therapy cycles 2
Common Pitfalls to Avoid
- Do not delay palliative care referral until end-of-life, as the median time between diagnosis and first palliative care consultation in retrospective studies was 473 days, missing opportunities for early symptom control 10
- Avoid focusing solely on disease-directed treatment markers; patient-reported outcomes (symptoms and functioning) should guide supportive care needs complementary to biomedical markers 1
- Do not assume asymptomatic periods mean no palliative care needs; 47.9% of patients in treatment-free intervals still report significant symptom burden 1
- Ensure dental hygiene counseling and regular dental check-ups to prevent ONJ, instructing patients to report tooth loosening, pain, swelling, or non-healing sores immediately 6