Living Well with Myeloma: A Focus on Bone Health

On October 14th, 2023, Dr. Rebecca Silbermann presented information on living well with myeloma to the Pacific Myeloma Community at the Seattle Round Table. You can watch the video from her excellent presentation or read the summary below. 

Patients are living longer with myeloma, an excellent fact that allows physicians to finally catch up when considering which treatment factors are the most important from a patient's perspective. 

One of those is bone health and how patients can still maintain a high quality of life (especially while exercising) with bone abnormalities or issues. 

Myeloma and Bone Health

Myeloma is the most frequent cancer to involve the bone, and up to 90% of patients develop bone lesions. Myeloma bone lesions can be asymptomatic, so it's important to get full body scans to detect any unknown bone lesions that can be at risk of fracturing. 

Myeloma cells play a direct role in stopping cells that produce bone. This is why myeloma can cause thinning of the bone, commonly known as osteopenia or osteoporosis. 

The goal of treatment for myeloma bone disease is to prevent fractures, prevent new bone destruction and bone loss, and improve pain caused by bone disease.

Treatment and Imaging for Bone Disease in Myeloma  

The current treatment of bone disease includes: 

• Biphosphonates (Zometa) 
• RANKL inhibitor (Xgeva) 

One of the two of these will most likely be given to you for a set period of time to manage bone disease and strengthen the bone.

When getting accurate bone imaging, the following tests are recommended: 

• Whole body CT 
• MRI/whole-body MRI 
• PET/CT 
• PET/MRI (in research, something that would be beneficial in the future) 

Bone scans underestimate skeletal involvement in multiple myeloma. X-rays just aren't sensitive enough for accurate imaging. 

The patients who need bone disease treatment are: 

• those who present with bone involvement at time of diagnosis 
• those on anti-myeloma therapy 
• those with osteoporosis or osteopenia due to multiple myeloma itself 

There are also certain procedures or medications that can improve painful bone lesions. 

• Local radiation 
• Kyphoplasty or Vertebroplasty
• Orthopedic Surgery 
• Pain medications (narcotics, patches, ibuprofen)
• Bone-directed therapy (Zometa, Xgeva) 

Risks of Bone-Directed Therapy 

There are some risks to bone-directed therapy, including ONJ (osteonecrosis of the jaw) and other dental problems. Be aware of these risks, meet with your dentist often, and if a dental emergency ever arises, talk to your oncologist about coming off of the bone strengtheners. 

Vitamin D and Calcium: How You Can Maintain Your Bone Health

Another way you can maintain your bone strength is through adequate calcium and vitamin D, as well as weight-bearing exercise where appropriate.    

Vitamin D promotes calcium absorption in the gut and is needed for bone growth and remodeling. Many myeloma patients need calcium supplements, even though they may have had high calcium levels previously. 

An estimated 40% of myeloma patients are Vitamin D deficient, which can contribute to musculoskeletal pain. A severe vitamin D deficiency can be associated with decreased muscle strength and increased fracture risk. 

The Institute of Medicine recommends 600-800 IU Vitamin D daily for adults, which is probably low. The "correct" dose for multiple myeloma patients is not clear. Talk to your doctor about what calcium and vitamin D doses are right for you. 

Is Exercise Medicine? 

Exercise is incredibly important but especially important to those getting cancer care. Many with myeloma are living with chronic pain and might be worried about exercising due to the bone lesions or issues that they have within their body. 

Educating yourself about smart exercise and knowing your limitations can be crucial to your health. 

Exercise can be helpful for symptom management like fatigue. They're hypothesized to contribute to a higher synergy for myeloma treatment. 

The benefits truly outweigh the risks. It's better for cancer patients to be as physically active as their abilities allow, not necessarily going on a run but avoiding inactivity. Continue your normal exercise and movement to keep your muscles and bones strong. 

Exercise prescriptions could be something that physicians implement in the future. Here is what an exercise prescription could look like around a stem cell transplant: 

Remember, you can start exercising anywhere, anytime. Talk to your doctor about connecting you with a physical therapist who can help you know your physical limitations if you have bone involvement with your myeloma. Make it a habit in your life! 

For those new to the exercise world or who have been avoiding exercise for one reason or another, starting with a physical therapist, as mentioned above, can be a great path for you. 

You can begin with gentler exercise modes like swimming, stretching, or tai chi. You can also hire a personal trainer to help you or connect with any exercise specialists in your area. 

Finding motivation can be difficult as well. Set goals (short and long-term) and seek social support from partners, friends, peers, and coaches. You can do this!