Two cancer patients, two eras of treatment

Fifteen years ago, diagnosing someone with multiple myeloma felt very different from today.

Not just because the disease itself was difficult, but because the road ahead was often physically and emotionally exhausting for everyone involved: the patient, the spouse, the children, and sometimes even the doctors looking after them.

The treatments were tougher then. Patients spent longer periods in hospital, side effects were often more pronounced, and even when treatment worked, there was usually an underlying understanding that the disease would eventually return.

There were fewer options once that happened, and many conversations with patients carried a quiet but unavoidable uncertainty.

Today, when I diagnose myeloma, the atmosphere in the room is still serious. It is still cancer after all. But the nature of the conversation has changed considerably.

Multiple myeloma is one of the more common blood cancers seen in Singapore, affecting several hundred patients each year. It is a cancer involving plasma cells, which are a type of immune cell found in the bone marrow.

Under normal circumstances, plasma cells produce antibodies that help protect us from infection. In myeloma, however, these cells become abnormal and multiply uncontrollably.

Over time, the abnormal plasma cells crowd out healthy blood-forming cells within the bone marrow and produce dysfunctional proteins that circulate in the blood. These proteins can damage organs, particularly the kidneys.

The disease also weakens bones by disrupting the body’s normal bone repair process, which is why many patients present with persistent back pain, fractures, or collapse of the spine. Others develop anaemia, severe fatigue, recurrent infections or unexplained weight loss.

One of the challenges with myeloma is that the symptoms can initially appear vague or unrelated. Many patients assume they simply have muscular back pain, stress, ageing or exhaustion from work.

By the time the diagnosis is eventually made, the disease may already have been present for quite some time.

I still remember a patient named Jang whom I looked after around 15 years ago. He was in his 40s, a lawyer with young children, and an enthusiastic runner.

We got along easily from the start because we were at similar stages of life. Both of us were balancing demanding careers, young families, and trying to maintain some degree of physical activity amid busy schedules.

He had been experiencing worsening back pain over several months. Initially, he assumed it was related to stress or a muscular injury from running, and like many people in their 40s, he simply pushed through it. But one morning, the pain became so severe that he could not get himself out of bed.

Scans showed extensive damage to his spine. Parts of the vertebrae had weakened and collapsed. Blood tests also revealed anaemia and kidney impairment, and further investigations quickly confirmed multiple myeloma.

Breaking news like this never becomes routine, no matter how many years one spends in medicine. I still remember sitting across from Jang and his wife in the consultation room as we explained the diagnosis.

The word “myeloma” was unfamiliar to them, but the moment we explained that it was a blood cancer, the mood in the room shifted immediately.

At that time, newer targeted therapies were only beginning to emerge. Before that, treatment relied far more heavily on conventional chemotherapy.

We were starting to see signs that outcomes were improving, but there was still significant uncertainty surrounding how long responses would last and what options remained if the disease returned.

Before we could even focus on the cancer itself, we first had to deal with his spine. His pain was severe, and orthopaedic surgeons had to stabilise the damaged areas and reinforce some of the collapsed bone so he could regain movement and function.

Only after that were we able to begin treatment properly. He started steroids and targeted therapy, and those first few months were difficult. There was the physical exhaustion from treatment, but also the emotional adjustment that follows a major diagnosis.

I remember his wife quietly taking notes during consultations so she would not miss anything important. I remember him trying to answer work e-mails from home because he wanted to preserve some sense of normality amid everything happening around him.

At one point during treatment, he asked me whether he would ever be able to run again. It was a simple question, but one that stayed with me because it reflected how patients often measure illness differently from doctors.

For us, we think about scans, blood results and remission. For patients, the important questions are often whether they can return to work, spend time with family, travel again, or simply regain parts of the life they previously took for granted.

People often think of cancer treatment as something experienced mainly by the patient, but in reality, entire families go through it together.

Daily routines revolve around clinic visits, scans and medications. Spouses become caregivers almost overnight. Children adapt quickly to changes they may not fully understand.

Jang eventually underwent a stem cell transplant, which at that time was a key part of treatment for suitable patients. The process involved high-dose chemotherapy followed by re-infusion of his own stem cells to help the bone marrow recover.

It was physically demanding. He lost weight and his hair, and there were days of weakness, nausea and isolation while waiting for his immune system to recover.

Gradually, though, things improved. His tumour markers fell, his pain became more manageable, and he entered remission. For a period of time, life regained some rhythm.

But myeloma is a disease that often returns. Unlike some cancers where treatment may eliminate the disease permanently, myeloma has traditionally been characterised by cycles of remission and relapse.

The challenge historically was that each relapse often became progressively harder to treat. When Jang’s disease eventually relapsed, we adjusted treatment again.

However, compared with today, the options available then were still relatively limited. Over time, the disease became increasingly difficult to control.

As doctors, these are the situations that remain with us long after the consultations end. There comes a point where the focus gradually shifts from aggressively controlling disease to preserving comfort, dignity and quality of life.

Jang died several years after his diagnosis, and I still think about him from time to time. Not only because of the disease, but also because of the stage of life he was in when it happened. Young children, an active career, and plans for the future that were interrupted much earlier than expected.

More recently, I met another patient whose story began in a remarkably similar way.

Similar age group, similar back pain, and ultimately the same diagnosis. But the journey that followed was very different.

By then, the treatment landscape for myeloma had changed significantly. Over the last two decades, entirely new categories of treatment have emerged.

Some therapies target specific pathways that myeloma cells rely on to survive, while others help the immune system recognise and attack the cancer more effectively.

More recently, highly specialised immune-based therapies have provided additional options even for patients whose disease has relapsed multiple times.

For patients, this has translated into something very tangible: longer periods of disease control, better quality of life, and importantly, the knowledge that there are often still further options available if the disease returns.

This newer patient underwent modern combination treatment followed by a stem cell transplant. Years later, when his disease began to show signs of returning, we were able to introduce another line of therapy, including newer immune-based treatment.

Once again, the disease came under control.

Today, our clinic conversations feel very different from the ones I used to have many years ago. We still discuss scans and blood counts, but we also talk about work, travel plans, family life and future arrangements.

There is still uncertainty because myeloma remains a serious disease, but there is also less fear that one relapse automatically means the end of meaningful treatment options.

Perhaps that is the greatest change I have witnessed over the course of my career. Not simply that patients are living longer, but that many are living more normally in between treatments.

The doctor-patient relationship also changes when you walk alongside someone over many years rather than months. You see children grow up, patients return to work, families slowly regain confidence, and life gradually rebuilds itself around the disease rather than being entirely defined by it.

Medicine has advanced tremendously, but when I think about progress in myeloma, I do not think first about statistics or drug names.

I think about time. Time with family, time to make plans again, and time to continue living life in a way that, years ago, would have been far more difficult to imagine.