Palliative Care of Multiple Myeloma Patients - a Nigerian Retrospective Outcome

Background: According to World Health Organization, Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification, assessment and treatment of pain, and other problems, physical, psychosocial and spiritual. Multiple Myeloma (MM) is one of the hematological malignancies that requires palliative care. This is because of the diagnostic dilemma it poses in resource-limited settings, its life-threatening nature and the suffering it inflicts on people living with it, especially in sub-Saharan Africa. Late presentation coupled with the complications of the disease worsen the prognosis of MM in this region, hence the need for palliative intervention. This study gives insight to the complications presented by people living with MM in the Niger-delta region of Nigeria and the outcome of various palliative interventions recruited to improve their quality of life.

Methodology: A-10-year multi-centered retrospective analysis of 26 patients diagnosed and managed in three major centers from January, 2003 to December, 2013. Information on the clinical, laboratory, radiological data as well as palliative treatment (supportive and definitive) was obtained at presentation and at 3 monthly intervals until patients were lost to follow-up.

Result: The median age of patients was 60.6 years with M:F ratio of 2.3:1. The mean duration before presentation was 11.8 months (11-48 months) with 61.5% (16), 30.8% (8),and 7.7% (2) presenting in Durie-salmon (DS) stage III,II and I diseases respectively. About 65.4% of the patients had a Performance status (PS) of III-IV (based on Eastern Co-operative Oncology Group (ECOG) classification)) while 34.6% had PS of I-II. The complications presented at diagnosis were anaemia (61.5%), pathological fracture (42.0%), nephropathy (23.1%), and hemiplegia (35%). The mean Hemoglobin concentration, Erythrocyte sedimentation rate (ESR), Bone marrow plasma cells (BMPC), serum creatinine, serum calcium and serum albumin were 7.8±5.1g/dl, 126.9±59.0 mm/hour, 38.5±33.5%, 256±192.5µmol/L, 2.51±0.8mmol/L and 36±9.3g/dl respectively. 25% (1/4) and 75% (3/4) were IgA- and IgG-types myeloma respectively. 70% (14/20) had osteopenic bone lesions. All (100%) the patients received analgesics (mainly NSAID regimens-non could access oral morphine) and hematinics (Iron supplements) as supportive interventions while 56.7%, 50.0%, and 19% had surgery, blood transfusion and renal hemodialysis respectively. Radiotherapy, Bisphosphonates, Erythropoietin and G-CSF (Neupogen) were received by 3.8%, 38%, 38%, and 11.4% of the patients respectively. 57.6% were on melphalan-prednisone (MP) double regimen while 19% and 8% were on MP-Thalidomide and MP-Bortezomib triple regimens respectively.8% were on Cyclophosphamide plus Prednisolone (CP). 3.8% at DS stage III-B disease had an Autologous Stem Cell Transplantation (ASCT). The mean survival interval was 13.12 months (95% CI, 6.65-19.58). The patients on MPV had longest duration of 72 months while the patients on CP had least duration of 2 months.

Conclusion: The PC of people living with advanced stage MM in Niger-Delta Nigeria is grossly inadequate. This could account significantly for the poor prognostic outcome of MM in the region. There is need to scale up palliative care of people living with MM via proper diagnosis, good supportive and definitive interventions. Oral morphine should be made availabe to alleviate the pains and sufferings due to bone lesions in this condition.