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Brain fog, fatigue and recurring mild fever: Symptoms of multiple myeloma and new treatments available
One key therapy for this form of blood cancer uses monoclonal antibodies so patients experience fewer side effects
Persistent fatigue and mental fog are symptoms commonly associated with multiple myeloma. PHOTO: GETTY IMAGES
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When Madam Thong Jinli started feeling fatigued from hot flashes and a recurring mild fever, she suspected something was wrong. “My symptoms made me feel drained and affected my work as a part-time tuition teacher,” the 71-year-old shares. Since no one in her family has had cancer, Madam Thong did not think that was the cause. Following a series of blood tests, however, she was diagnosed with multiple myeloma.
The second most common blood cancer in Singapore after lymphoma, multiple myeloma is diagnosed in over 100 patients here each year. It is a cancer that originates in the bone marrow and affects the body’s plasma cells, which are responsible for producing antibodies to help protect against infection. In multiple myeloma, the cancerous plasma cells produce abnormal antibodies known as M-proteins and crowd out healthy blood cells. These myeloma cells also damage and weaken the bone.
Dr Chandramouli Nagarajan, senior consultant at Singapore General Hospital, explains that in almost all patients, multiple myeloma is preceded by a blood condition called Monoclonal Gammopathy of Undetermined Significance (MGUS), where some of the body’s plasma cells make M-proteins.
However, as MGUS is not a blood cancer, it does not mean that people with the condition will go on to develop multiple myeloma. In certain cases, MGUS may even regress or disappear altogether.
Risk factors, signs and when to seek help
Family history is a known risk factor for multiple myeloma, with first-degree relatives, such as parents, siblings and children, two to three times more likely to develop the disease. It tends to affect people above the age of 55 and is also slightly more common in men, although the reason for this is unclear.
Common symptoms of multiple myeloma include bone pain, particularly in the back or chest, frequent infections, fatigue or exercise intolerance, constipation, loss of appetite, mental fogginess, weight loss, weakness or numbness in your legs and excessive thirst.
As many of these symptoms are non-specific and could be due to other conditions, Dr Chandramouli advises making an appointment with a physician if any of the above symptoms are persistent.
Advancements in medical treatments
With multiple myeloma, the first-line treatment is usually chemotherapy given in two or three phases depending on whether a bone marrow transplant is planned, says Dr Chandramouli. “The first phase is induction therapy, which aims to reduce the tumour bulk in a newly diagnosed patient.
The second phase is known as 'consolidation', and is typically a bone marrow transplant given to deepen the remission state achieved by the induction therapy. Lastly, the maintenance phase is to prolong the remission state, usually with drugs that work on the patient’s own immune system,” he explains.
After completing her course of chemotherapy, Madam Thong underwent an autologous stem cell transplant in 2017, a process which uses her own healthy blood cells to replace malfunctioning bone marrow. However, she found that her memory was starting to fail, in addition to other side effects like shaky hands.
“Whenever I ate out at hawker centres, I remember spilling soup on myself because my hands kept shaking when I held the bowl and I felt so embarrassed,” Madam Thong shares. She also experienced diarrhoea on alternate days and felt tired. “I had to take three 15-minute power naps every day,” she says.
In 2021, she had a relapse. Her doctors, Professor Goh Yeow Tee and Dr Chandramouli, then advised her to start on a new combination monoclonal antibody therapy under an early access programme, prior to registration approval by the Health Sciences Authority in Singapore. This is where patients with a serious or life-threatening disease can get access to an experimental medicine outside of a clinical trial, when no comparable or satisfactory alternative is available.
“Monoclonal antibodies are a special form of targeted treatment that binds to a particular protein on the surface of a myeloma cell, tagging it for destruction by the patient’s own immune cells,” explains Dr Chandramouli. He adds that, since monoclonal antibodies are more precise when attacking cancer cells, fewer normal cells are affected during the therapy, which results in fewer side effects.
For Madam Thong, each treatment requires a blood test and then several intravenous and pre-medication injections. The entire process takes two hours and she also has to be on oral medication for three weeks every month.
Recent clinical trials have shown an extremely low number of cancer cells remaining in the body following immunotherapy treatments, potentially giving newly diagnosed patients a sustained period of remission.
According to Dr Chandramouli, it is helpful for patients to learn more about multiple myeloma, its various stages, available treatments and potential risks of each treatment. “This will be useful when communicating with doctors and in the planning of one’s treatment plan,” he says. “The key to optimal survival in myeloma is access to various myeloma therapeutics, without which, patients like Madam Thong would have only had the option to be treated with an earlier generation of anti-myeloma drugs and other less effective agents, each with their own side effects.”
Although updates to the Cancer Drug List – implemented earlier this year by the Ministry of Health – have enabled patients to get wider insurance coverage, financial considerations may still weigh on patients’ minds, especially in diseases like multiple myeloma, which needs long-term management.
To this end, patients can ask their doctors about any suitable clinical trials they can participate in, both easing the financial burden and offering an avenue to new therapies. “Trials can provide access to drugs that may not yet be commercially available or affordable for the patient and, sometimes, they might be the only way to get access to some of these novel therapies,” Dr Chandramouli elaborates.
Since receiving the new monoclonal antibody therapy, Madam Thong continues to lead her life as normally as possible. "I do the things that make me happy each day, like Zumba, line dancing and aerobics,” she says. She also advises patients with multiple myeloma to build trust with their doctor, keep active and join patient forums that local hospitals provide.
Agreeing, Dr Chandramouli says, “Even though multiple myeloma is an incurable disease, many people are still able to manage the disease and lead fulfilling lives. Staying positive, focusing on the things that bring one joy and purpose, and building a support network are things that one can focus on while navigating this disease.”
If you think you may be experiencing symptoms of multiple myeloma, please consult your doctor or medical professional for further discussion and treatment options.
* Reproduced and adapted with permission from The Royal Australian College of General Practitioners from: ‘Figure 3. Treatment flow chart for newly diagnosed multiple myeloma’. Eslick R, Talaulikar D. Multiple myeloma: From diagnosis to treatment. Aust Fam Physician 2013; 42(10):684–8. Available at www.racgp.org.au/afp/2013/october/multiple-myeloma#ref-12
