Multiple Myeloma Definition Multiple myeloma is a cancer of your plasma cells. Plasma cells are a type of wh ite blood cell present in your bone marrow. In multiple myeloma, a group of abno rmal plasma cells (myeloma cells) multiplies, raising the number of plasma cells to a more than normal level. The result can be erosion of your bones. The disea se also interferes with the function of your bone marrow and immune system, whic h can lead to anemia and infection. Multiple myeloma may also cause kidney probl ems. The disease is called multiple myeloma because myeloma cells can occur in m ultiple bone marrow sites in your body. If you have multiple myeloma but don't h ave symptoms, your doctors may just monitor your condition. If you're experienci ng symptoms, various treatments are available. Symptoms Although multiple myeloma may not cause symptoms early in the disease, it's like ly that you'll experience signs and symptoms as the disease progresses. Signs an d symptoms of the disease can vary from person to person. Common multiple myelom a symptoms include:

Bone pain. Presence of abnormal proteins which can be produced by myeloma cells in your blood or urine. These proteins which are antibodies or parts of antibodi es are called monoclonal, or M, proteins. Often discovered during a routine exam , monoclonal proteins may indicate multiple myeloma, but also can indicate other conditions. High level of calcium in your blood. This can occur when calcium fr om affected bones dissolves into your blood. If you have a high calcium level in your blood, you may experience signs and sym ptoms such as: Excessive thirst and urination Constipation Nausea Loss of appetite Mental confu sion

Anemia can occur as myeloma cells replace oxygen-carrying red blood cells in you r bone marrow, which may lead to another common symptom fatigue. Other signs and symptoms of multiple myeloma may include: Bone pain, particularly in your back or ribs Unexplained bone fractures Repeated infections such as pneumonia, bladder or kidney infection, or sinusitis Weight loss Weakness or numbness in your legs Causes Although the exact cause isn't known, doctors do know that multiple myeloma begi ns with one abnormal plasma cell in your bone marrow the soft, blood-producing t issue that fills in the center of most of your bones. This abnormal cell then st arts to multiply. Because abnormal cells don't mature and then die as normal cel ls do, they accumulate, eventually overwhelming the production of healthy cells. Healthy bone marrow consists of a small number of plasma cells, less than 5 per cent. But in people with multiple myeloma, the number of plasma cells often incr eases to more than 10 percent. Because myeloma cells may circulate in low number s in your blood, they can populate other bone marrow sites in your body, even fa r from where they began. Uncontrolled plasma cell growth can damage bones and su rrounding tissue. It can also interfere with your immune system's ability to fig ht infections by inhibiting your body's production of normal antibodies. Researc hers investigating cause Experts aren't sure why this process begins. But, resea rchers are studying the DNA of plasma cells to try to understand what changes oc cur that cause these cells to become cancer cells. Though they haven't yet disco vered the cause of these changes, they have found some common abnormalities in m yeloma cells. For example, many myeloma

cells are missing all or part of one chromosome chromosome 13. Cells with a miss ing or defective chromosome 13 tend to be more aggressive and harder to treat th an are cells with a normal chromosome 13. A connection with MGUS Multiple myelom a sometimes develops from a condition called monoclonal gammopathy of undetermin ed significance (MGUS). MGUS is more common in adults over age 50. This conditio n, like multiple myeloma, is marked by the presence of M proteins produced by ab normal plasma cells in your blood. However, in MGUS, the amount of the abnormal proteins isn't high enough to cause harm, and no damage to the bones occurs. Risk factors Multiple myeloma isn't contagious. Most people who develop multiple myeloma have no clearly identifiable risk factors for the disease. Some factors that may inc rease your risk of multiple myeloma include:

Age. The majority of people who develop multiple myeloma are older than 50, with most diagnosed around age 70. Few cases occur in people younger than 40. Sex. M en are more likely to develop the disease than are women. Race. Blacks are about twice as likely to develop multiple myeloma as are whites. History of a monoclo nal gammopathy of undetermined significance. Every year 1 percent of the people with MGUS in the United States develop multiple myeloma. Obesity. Your risk of m ultiple myeloma is increased if you're overweight or obese. Other factors that may increase your risk of developing multiple myeloma include exposure to radiation and working in petroleum-related industries. When to seek medical advice If you're persistently more tired than you used to be, you've lost weight, and y ou experience bone pain, repeated infections, loss of appetite, excessive thirst and urination, persistent nausea, increased constipation, or weakness or numbne ss in your legs, your signs and symptoms may indicate multiple myeloma or other serious diseases. See your doctor to determine the underlying cause. Tests and diagnosis Your doctor may first detect signs of multiple myeloma before you ever have symp toms through blood and urine tests conducted during a routine physical exam. If you don't yet have symptoms, these lab tests may be repeated every few months so

that your doctor can track whether your disease is progressing and determine the best time to start treatment. Blood and urine tests A blood test called serum p rotein electrophoresis separates your blood proteins and can detect the presence of M proteins, called an "M spike," in your blood. Parts of M proteins may also be detected in a test of your urine when found in urine, they're referred to as Bence Jones proteins. If your doctor discovers M proteins, you'll likely need a dditional blood tests to measure blood cell counts and levels of calcium, uric a cid and creatinine. Your doctor may also conduct other blood tests to check for beta2-microglobulin another protein produced by myeloma cells or to measure the percent of plasma cells in your bone marrow. Other tests You may also need other tests. They may include:

Imaging. X-rays of your skeleton can show whether your bones have any thinned-ou t areas, common in multiple myeloma. If a closer view of your bones is necessary , your doctor may use magnetic resonance imaging (MRI) or computerized tomograph y (CT) scanning. Bone marrow examination. Your doctor may also conduct a bone ma rrow examination by using a needle to remove a small sample of bone marrow tissu e. The sample is then examined under a microscope to check for myeloma cells. Staging and classification These tests can help confirm whether you have multipl e myeloma or another condition. If tests indicate you have multiple myeloma, the results from these tests allow your doctor to classify your disease as stage 1, stage 2 or stage 3. People with stage 3 myeloma are more likely to have one or more signs of advanced disease, including greater numbers of myeloma cells and k idney failure. Complications Multiple myeloma can result in several complications:

Impaired immunity. Myeloma cells inhibit the production of antibodies needed for normal immunity. Having multiple myeloma may make you more likely to develop in fections, such as pneumonia, sinusitis, bladder or kidney infection, skin infect ions and shingles. Bone problems. Multiple myeloma also can affect your bones, l eading to erosion of bone mass and fractures. The condition may cause compressio n of your spinal cord. Signs of this medical emergency include weakness, or even paralysis, in your legs. Impaired kidney function. Multiple myeloma may cause p roblems with kidney function, including kidney failure. Higher calcium levels in the blood related to eroding bones can interfere with your kidneys' ability to filter your

blood's waste. The proteins produced by the myeloma cells can cause similar prob lems, especially if you become dehydrated. Anemia. As cancerous cells crowd out normal blood cells, multiple myeloma can also cause anemia and other blood probl ems. Treatments and drugs Generally, if you have multiple myeloma and aren't experiencing symptoms, you do n't need treatment. However, your doctors will likely monitor your condition at variable intervals, checking for signs such as increasing levels of M protein in your blood or urine that indicate the disease is progressing. If it is, you may need treatment to help prevent symptoms. In people diagnosed with asymptomatic multiple myeloma, the risk of developing symptoms is about 10 percent a year for the first five years after learning that they have the disease. If you're exper iencing symptoms, treatment can help relieve pain, control complications of the disease, stabilize your condition and slow the progress of the disease. Standard treatments for myeloma Though there's no cure for multiple myeloma, with good t reatment results you can usually return to near-normal activity. The appropriate multiple myeloma treatment depends on your needs, medical status and general he alth. You may also wish to consider approved clinical trials as an option. Stand ard treatment options include:

Chemotherapy. Chemotherapy involves using medicines taken orally as a pill or gi ven through an intravenous (IV) injection to kill myeloma cells. Chemotherapy is often given in cycles over a period of months, followed by a rest period. Often chemotherapy is discontinued during what is called a plateau phase or remission , during which your M protein level remains stable. You may need chemotherapy ag ain if your M protein level begins to rise. Common chemotherapy drugs used to tr eat myeloma are melphalan (Alkeran), cyclophosphamide (Cytoxan), vincristine (On covin), doxorubicin (Adriamycin) and liposomal doxorubicin (Doxil). Corticostero ids. Corticosteroids such as prednisone and dexamethasone (Decadron) have been u sed for decades to treat multiple myeloma. They are typically given as pills. So me research suggests that high doses of steroids may not be needed, and that low er doses may be safer and more effective. Stem cell transplantation. This treatm ent involves using high-dose chemotherapy usually high doses of melphalan along with transfusion of previously collected immature blood cells (stem cells) to re place diseased or damaged marrow. The stem cells can come from you or from a don or, and they may be from either blood or bone marrow. Thalidomide (Thalomid). Th alidomide, a drug originally used as a sedative and to treat morning sickness in the 1950s, was removed from the market after it was found to cause severe birth defects. However, the drug received approval from the Food and Drug Administrat ion (FDA) again in 1998, first as

a treatment for skin lesions caused by leprosy. Thalidomide is currently FDAappr oved in conjunction with the corticosteroid called dexamethasone for the treatme nt of newly diagnosed cases of multiple myeloma. This drug is given orally. Bort ezomib (Velcade). Velcade was the first approved drug in a new class of medicati ons called proteasome inhibitors. It is administered intravenously. It works by blocking the action of proteasomes, which causes cancer cells to die. One study showed that bortezomib had more than twice the response rate of a commonly used drug, dexamethasone. Bortezomib is approved by the FDA for use in a treatment fo r people with multiple myeloma who have received at least one prior therapy. Len alidomide (Revlimid). Lenalidomide is chemically similar to thalidomide, but app ears to be more potent and cause fewer side effects. It is given orally. Lenalid omide is FDA-approved for use in combination with dexamethasone as a treatment f or people who have received at least one prior therapy for multiple myeloma. Rad iation therapy. This treatment uses high-energy penetrating waves to damage myel oma cells and stop their growth. Radiation therapy may be used to target myeloma cells in a specific area for instance, to more quickly shrink a tumor that's ca using pain or destroying a bone. Initial therapy for myeloma The initial chemotherapy used to treat multiple myel oma depends on whether you're considered a candidate for stem cell transplantati on. Factors such as the risk of your disease progressing, your age and your gene ral health play a part in determining whether stem cell transplantation may be r ight for you. If you're considered a candidate for stem cell transplantation: Your initial the rapy will likely exclude melphalan because this drug can have a toxic effect on stem cells, making it impossible to collect enough of them. You may begin treatm ent with the most common initial myeloma therapy in the United States, thalidomi de plus dexamethasone. Or your doctor may instead recommend a newer regimen, len alidomide plus low-dose dexamethasone. Your stem cells will likely be collected after you've undergone three to four months of treatment with these initial agen ts. Your doctor may recommend undergoing the stem cell transplant soon after you r cells are collected or delaying the transplant until after a relapse, if it oc curs. Your age and your personal preference are important factors that will help your doctor make his or her recommendation.

If you're not considered a therapy is likely to be a (MPT). If the side effects option (MP). This type of

candidate for stem cell transplantation: Your initial combination of melphalan, prednisone and thalidomide are intolerable, melphalan plus prednisone is another therapy is typically given for about 12 to 18 months.

Treatments for relapsed or treatment-resistant multiple myeloma Most people who are treated for multiple myeloma eventually experience a relapse of the disease. And in some cases, none of the currently available, first-line therapies

slow the cancer cells from multiplying. If you experience a relapse of multiple myeloma, your doctor may recommend repeating another course of the treatment tha t initially helped you. Another option is trying one or more of the other treatm ents typically used as first-line therapy, either alone or in combination. Resea rch on a number of promising new treatment options is ongoing, and these drugs o ffer important options for those with multiple myeloma. Talk to your doctor abou t what clinical trials may be available to you. Treating complications Because m ultiple myeloma can cause a number of complications, you may also need treatment for those specific conditions. For example:

Back pain. Taking pain medication or wearing a back brace can help relieve the b ack pain you might experience with multiple myeloma. Kidney complications. Peopl e with severe kidney damage may need dialysis. Infections. Antibiotics may be ne cessary to help treat infections or to help reduce your risk of them. Bone loss. You may take medications called bisphosphonates, such as pamidronate (Aredia) o r zoledronic acid (Zometa), which bind to the surface of your bones and help pre vent bone loss. Treatment with these drugs is associated with the risk of harm t o the jawbone. If you're taking these medications, don't have dental procedures done without consulting your doctor first. Anemia. If you have persistent anemia , your doctor may prescribe erythropoietin injections. Erythropoietin is a natur ally occurring hormone made in the kidneys that stimulates the production of red blood cells. Research suggests that the use of erythropoietin may increase the risk of blood clots in some people with myeloma. Lifestyle and home remedies The following tips may help you keep multiple myeloma under control:

Stay active. Exercise helps keep your bones stronger. If pain keeps you from bei ng active, ask your doctor about ways to lessen the pain. Drink fluids. Drinking fluids can help keep you from becoming dehydrated. And by drinking plenty of fl uids, you help dilute the Bence Jones protein fragments in your urine, which may help prevent kidney damage. Eat a balanced diet. One way to promote your overal l health and cope with any form of cancer is to eat well. The amount of M protei n in your system isn't affected by how much protein you eat, so there's no need to limit protein intake unless told otherwise by your doctor. Don't take vitamin s, herbs or medications without your doctor's approval because they may interfer e with your treatment. Coping and support

A diagnosis of cancer can be extremely challenging. Remember that no matter what your concerns or prognosis, you're not alone. These strategies and resources ma y make dealing with cancer easier:

Know what to expect. Find out everything you can about your cancer the type, sta ge, risks, your treatment options and their side effects. The more you know, the more active you can be in your care. In addition to talking with your doctor, l ook for information in your local library and on the Internet. The National Canc er Institute will answer questions over the phone from the public at 800-4-CANCE R, or 800-422-6237. Or contact the American Cancer Society at 800-ACS-2345, or 800-227-2345. Information is also available on their Web sites. Be proactive. Al though you may feel tired and discouraged, don't let others including your famil y or your doctor make important decisions for you. It's vital that you take an a ctive role in your treatment. Maintain a strong support system. Having a support system and a positive attitude can help you cope with any issues, pain and anxi eties that might occur. Although friends and family can be your best allies, the y sometimes may have trouble dealing with your illness. If so, the concern and u nderstanding of a formal support group or others coping with cancer can be espec ially helpful. Although support groups aren't for everyone, they can be a good s ource for practical information for you and your family, too. You may also find you develop deep and lasting bonds with people who are going through the same th ings you are. Set reasonable goals. Having goals helps you feel in control and c an give you a sense of purpose. But don't choose goals you can't possibly reach. You may not be able to work a 40-hour week, for example, but you may be able to work at least part time. In fact, many people find that continuing to work can be helpful. Take time for yourself. Eating well, relaxing and getting enough res t can help combat the stress and fatigue of cancer. Also, plan ahead for the dow ntimes, when you may need to rest more or limit what you do. Stay active. Having cancer doesn't mean you have to stop doing the things you enjoy or normally do. For the most part, if you feel well enough to do something, go ahead and do it. It's important to stay involved as much as you can.