Aggressive drug regimens with multiple agents have their place, but you also have to use clinical judgment regarding the patient, the disease, and what the patient can tolerate to determine when to back off with aggressive therapy. For instance, patients who are going into hospice care do not require aggressive treatment for their multiple myeloma. HRQoL is used to measure the aspects of quality of life that are most often affected by health or illness. With multiple myeloma, you can see significant bone pain, vulnerability to infection, fatigue, and other symptomatology, all of which can severely impact HRQoL. Consequently, HRQoL and supportive-care issues warrant significant attention. Clinicians should focus on treating the whole person rather than simply just counting complete remission and progression-free survival rates. It is also important to distinguish between the effects of multiple myeloma itself and those of comorbidities and to treat accordingly to impact the patient’s HRQoL. If you are focused only on the multiple myeloma, it will be to the detriment of the patient’s health. For instance, bone disease is complicated, and it is often undertreated; a fracture might be from osteoporosis and not multiple myeloma. Some 30% to 40% of these patients have vitamin D deficiency, which, in addition to its impact on bone disease, contributes to treatment-associated neuropathy. Then, additional concerns are introduced if calcium levels are high.

Supportive care is for the whole patient, not just for multiple myeloma. I just saw a patient with virtually no platelets and a hemoglobin level of 6 mg/dL, and she was never administered intravenous iron; she also has myelodysplasia contributing to her anemia, but all of this was attributed to the multiple myeloma. Many patients with kidney failure are being treated for their multiple myeloma when their kidney failure is actually being caused by diabetes or hypertension. Kidney disease should be treated aggressively, otherwise patients can wind up on dialysis when it can actually be avoided. One example is a man we started seeing 8 years ago. His labs are amazing now, and he has plans to climb Mount Kilimanjaro to raise money for multiple myeloma research. So, it is important to remember that not every lab and bone problem that can be associated with multiple myeloma is necessarily caused by multiple myeloma.