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Strategies for Managing Bone Pain in Multiple Myeloma Patients

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Published on July 15, 2021

How Can Patients With Multiple Myeloma Manage Bone Pain?

Individuals with multiple myeloma often experience bone pain, weakness, and numbness or tingling. Follow along as Patient Power co-founder Andrew Schorr has an in-depth conversation with Betsy O'Donnell, MD, of the Multiple Myeloma Disease Center at Massachusetts General Hospital, about bone health. This includes strategies for managing bone pain, what scans to expect during diagnosis, the effectiveness of certain treatments, and how diet and vitamins can affect bone-directed therapy.

Support for this series has been provided by Sanofi Genzyme. Patient Power maintains complete editorial control and is solely responsible for program content.

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Transcript | Strategies for Managing Bone Pain in Multiple Myeloma Patients

Andrew Schorr: Hello, and welcome to Patient Power. I'm Andrew Schorr, in San Diego, and joining us from Boston, Massachusetts is a myeloma specialist, Dr. Betsy O'Donnell. She's at Massachusetts General, where she is the Director of Lifestyle Medicine, and as I said, is a myeloma specialist. Welcome to Patient Power.

Dr. O'Donnell: Thank you so much. It's wonderful to be here.

Andrew Schorr: Dr. O'Donnell, I want to talk about myeloma and bones. I've interviewed people who found out they had myeloma when their grandchild hugged them, and they cracked a couple of ribs. What's the connection between myeloma and your bones?

What Is the Connection Between Multiple Myeloma and Bone Health?

Dr. O'Donnell: That's a great question. So, what does multiple myeloma even mean? It means multiple tumors of the bone marrow. This is a disease that is, the cancer cells grow inside your bone marrow. But in addition to that, it can make tumors in the bone from plasma cells. People with multiple myeloma may have thinner bones but may also have tumors that are at risk of fracture, just like you've described. Weaknesses within the ribs that can then break, when hugged tightly, or even making sudden movements, or sneezing.

Andrew Schorr: Wow. Okay, so when you have a new myeloma patient, or even along their journey with myeloma, what scans do you do to see what is the involvement of the bones?

Dr. O'Donnell: That's a really great question. We know that up to 80% of patients who have multiple myeloma, at some point, will have involvement of their bones. There are a bunch of different ways that we can image bones. The most basic way is through what's called a skeletal survey, which are just plain X-rays of many bones in your body. But we really replace that with some more sensitive scans. What I mean by more sensitive is, it enables us to pick up smaller bone lesions. Something like a low-dose CT scan is one modality we use, which can look at all of the bones in your body. Other imaging can be whole body MRI or a PET scan that uses a radioactive glucose molecule, along with imaging, to see where there are areas of multiple myeloma or other cancers in your body.

Andrew Schorr: Okay. Now that could be done at different points in someone's myeloma journey. Maybe they didn't have these scans early on, but later, you might say, I think we need to do it, right?

Dr. O'Donnell: That’s right. It's very useful when someone is first diagnosed with multiple myeloma to have complete bone imaging, because that then serves as a baseline. So that if there is a new pain, we have a frame of reference to compare it and see if something new is going on, particularly if someone has been on a therapy for a long time.

Andrew Schorr: All right, now what's the connection between bone pain and bone lesions? Could the scan show lesions where people didn't even know?

Dr. O'Donnell: Absolutely, so that's another really great question. So, the outside of the bone, that cortex, has nerves in it and can be very sensitive. If a bone lesion or tumor touches into that space, it can become painful. But other spots within the bones may not be as sensitive or cause pain.

Andrew Schorr: Okay. Now where, for a myeloma patient, are the typical places where they'd have these bone lesions in the body?

Dr. O'Donnell: Well, so very often it's along the axial skeleton, meaning your spine, your pelvis. Sometimes we see them in the upper arms or in the thigh bones, but the spine is a very common place, and just as you've described, people can have rib fractures, like you mentioned.

Andrew Schorr: Okay. I’ve got two questions, and I know you're an athlete. I know that all of us, and I'm a cancer patient too, being active as a good thing.

Dr. O'Donnell: Yes.

Andrew Schorr: It can reduce fatigue. It's good for us, our overall health, et cetera. But if you have bone lesions, oh my God, you're worried about fractures. So how do you counsel myeloma patients on what they can do, and maybe what they should avoid?

Can Patients With Bone Lesions Continue to Exercise?

Dr. O'Donnell: Such an important question, and so, it's not a one size fits all answer. So, some cancers, more so than others, have a propensity to affect the bones. Myeloma is one that does, and not all bone lesions are of the same significance. If it's something tiny in a non-weight-bearing bone, or not involving the cortex of the bone, then you may be able to do certain types of exercises. However, if it's an area that bears weight, or is at risk of fracture because of the size of it, then you have to be very careful about the things you do. Just like you said, we want people to be active, and specifically, we want people to avoid inactivity. But if you're thinking about exercising and particularly things that are weight-bearing, like running, or lifting heavy things, that's a very important conversation to have with your oncologist, to make sure that's a safe activity for you.

Andrew Schorr: All right, let's go on to treatments. So I think we've talked so often with myeloma patients about the broad range of treatments for myeloma now, doublets and triplets and quadruplets of medicines. What about treatment for bone lesions? What do you do about that and bone-strengthening?

What Is Bone-Directed Therapy?

Dr. O'Donnell: Yup. So all myeloma patients, unless they have a specific reason not to receive bone-directed therapy, should receive bone-directed therapy, to help strengthen the bones and prevent further damage to the bones. There are several approved drugs that are recommended for multiple myeloma, which includes zoledronic acid (Zometa) and denosumab (Xgeva and Prolia), which are two different classes of drugs, equally effective, that can help strengthen the bones and should be administered during myeloma therapy as a supplemental medication.

Andrew Schorr: Okay. Let me see if I've got this straight. So, you might be on a pill for myeloma. You might be on an infused medicine, like a monoclonal antibody for the myeloma itself, and then you might be on an additional medicine for your bones.

Dr. O'Donnell: That's right. So, this is something in addition to your cancer medications, it is not a chemotherapy or a cancer drug. These are actually drugs that have been used historically for osteoporosis, that are used at slightly different doses, for helping the bones heal and strengthen from cancer. This is something that's done often monthly during the initial phase of treatment; they may be spaced out to every three months or so throughout the course of your myeloma therapy, in addition to your cancer treatment.

Andrew Schorr: Let's talk about calcium for a minute. So, people understand that calcium, we were told when we were growing up, "Drink milk and you'll get calcium,” and all this stuff, “Strengthen your bones." What about somebody taking a supplement, or anything like that? Would that be helpful?

Dr. O'Donnell: Well, so it's interesting. And again, this is where you work closely with your oncologist. One of the defining features of multiple myeloma at the time of diagnosis or at relapse can be high calcium levels. Very often that's related back to those bone tumors that can destroy bone and free up calcium. If you have high calcium, then you would not want to be on a calcium supplement. However, the way the drugs that strengthen your bone work is, they use your calcium to help build those new bones. Most patients almost universally require calcium and vitamin D supplementation, while they do bone-directed therapy so that their calcium levels remain in a normal range and don't go too low.

Andrew Schorr: Okay. What about other things in diet? Is there something that somebody should eat, vegetables, or other kinds of things that would be good, that could also help them overall with their bones?

Are Certain Diets Recommended for Improving Bone Health?

Dr. O'Donnell: In general, the American Cancer Society recommends a plant-based diet. That means eating two-thirds of your diet coming from fruits and vegetables and whole grains. That can be hard for some people, but that idea, that when you look down at your plate, it should be fruits and vegetables, is a good principle. Trying to eat diverse foods that are rich in nutrients is a really good idea to help supplement the vitamins that you're getting. There's no better way to take in vitamins than to consume them in real food. In terms of proteins and other sources of nutrition in general, minimizing red meat, so no more than one serving of red meat per week is recommended. Looking at alternate sources like fish or nuts for your protein is recommended as well.

Andrew Schorr: Now you've mentioned, along the way you’ve mentioned that when you're talking about the medicines used in osteoporosis, some older people with myeloma may have been developing osteoporosis, anyway. So, is there a twofer here, that they can help with the osteoporosis and the myeloma?

Dr. O'Donnell: Yes, absolutely. Again, osteoporosis can actually be a disease-defining feature of multiple myeloma as well. So really, what we understand is that the precious balance between building and destroying bone that's constantly going on inside your bone marrow is thrown off when people have myeloma. So, trying to correct those factors and restrengthen the bone, whether it be because you have a bone lesion, or osteoporosis, is beneficial.

Andrew Schorr: All right. So, help me understand if this bone destruction is a one-way trip, or if you can improve. In other words, if somebody's had some lesions, and they're on these bone strengthening agents, can they get back to a better place?

Can These Treatment Strategies Lessen Bone Pain?

Dr. O'Donnell: Absolutely. They can get back to a better place, the bone can heal. Very often, we'll re-image people down the road. We don't always expect to see that those spots go away. But what we want to see is that there's a scarred healing rim around them, and that the cancer within them is gone. That's something that a PET scan can be useful to see if there is inappropriate activity within a spot in the bone. And with myeloma treatment and with bone strengtheners, we absolutely can help heal bone.

Andrew Schorr: Well, let me just see if I've got all this right, just to summarize for our audience. So first of all, myeloma affects the bones. Scans are important and may be at different times in your journey. Working with your myeloma doctor, probably often including a bone strengthening agent, some dietary things, and consulting with you on what exercise is safe, given what's seen in their bones. Did I get it right?

Dr. O'Donnell: You did. I'd like to add one additional thing, too. Physical therapy is often underutilized, in general, in the cancer population. Your oncologist can also refer you to physical therapy and have people work with you, that insurance will cover, to help strengthen the muscles that support your spine, and your other bones, and limit your risk of falling. So, consider that as another way to help protect yourself, and work on your physical wellness.

Andrew Schorr: Dr. O'Donnell. I'd like to ask all our myeloma specialists this question. With all the tools that you have now and the knowledge, and you're at one of the top institutions, Massachusetts General, are you encouraged that your myeloma patients, with bone-strengthening, with the cancer-fighting drugs, with the right diet, can live longer and live better these days?

Dr. O'Donnell: Absolutely. I think it's just been remarkable, and I've been doing myeloma for almost a decade. And the progress that's occurred in it is just evolving so rapidly, is so encouraging and inspiring. And I think there's so much hope for all of our patients out there with myeloma.

Andrew Schorr: Well, thank you for your devotion to myeloma research and myeloma patients. Dr. Betsy O'Donnell, from Massachusetts General. Thanks for being on Patient Power.

Dr. O'Donnell: Thank you so much for having me.

Andrew Schorr: I'm Andrew Schorr. Remember, knowledge can be the best medicine of all.


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