23 February 2016

Improving and Standardising Care for People with Incurable Blood Cancer

Latest NICE guidance aims to help improve and standardise the diagnosis, treatment and monitoring of myeloma.

The recommendations cover a range of areas including offering communication and support, imaging tests, and palliative care services.

Myeloma is a form of cancer that arises from plasma cells – a type of white blood cell made in the bone marrow. The cancer affects a number of organs including the bones, kidneys, blood and immune systems.

While the cancer is relatively rare, its incidence has increased over time in Great Britain since the late-1970s. Rates of myeloma also tend to be significantly higher among black people than those from other ethnicities.

There is currently no cure for myeloma, however there are treatments that can reduce the number of myeloma cells in the body, help with the symptoms and improve quality and length of life.

NICE’s latest guideline aims to address uncertainty or variation in practice in several areas including communication and support, investigation, imaging, side effects, and palliative care.

Providing information and support

A number of recommendations underpin the guideline. They call for information and support to be offered to people with myeloma and their families or carers.

NICE recommends that healthcare professionals should consider information on a number of topics. These include the treatment plan, symptoms of myeloma and treatment-related side effects, and how to identify and report new symptoms.

The guideline also recommends offering prompt psychological assessment and support to people with myeloma at diagnosis. This should additionally be carried out at the beginning of each treatment and when a patient is coming to the end of their life.

Listen to Professor Sam Ahmedzai, a member of the guideline committee, talk about the recommendations on information and support and the impact that the guideline has on palliative care.

Laboratory investigations and imaging for people with suspected myeloma

Among the tests used for myeloma is a bone marrow aspirate and biopsy. A surgical team extracts a sample from the bone marrow to see if there are any abnormal cells.

NICE recommends using the same sample for all diagnostic and prognostic tests on bone marrow. This means that people only have to have one bone marrow aspirate (extracting a sample with a syringe) and trephine biopsy (where a piece of bone marrow is removed).

The guideline says that imaging should be offered to all people with a plasma cell disorder suspected to be myeloma.

Since myeloma can appear anywhere in the body, a full MRI scan should be considered as first-line imaging. Furthermore, whole-body low-dose CT should be considered as first-line imaging if whole-body MRI is unsuitable or the person declines it.

NICE says that skeletal survey should only be considered as first line imaging if whole body MRI and whole body low dose CT are unsuitable or the person declines them.

Dr Nicola Mullholland, a member of the guideline development group, talks more about imaging and the rationale behind the recommendations: listen here

Ensuring adequate service provision for myeloma

NICE makes a number of recommendations on the services and facilities required for people with myeloma.

It says each hospital treating people with myeloma who are not receiving intensive inpatient chemotherapy or a transplant should provide access to support. This could include a multidisciplinary team specialising in myeloma and, supportive and palliative care, clinical trials via the specialist myeloma team, and dental services.

In addition, each hospital treating people with myeloma should provide regional access through its network to a range of facilities including renal support, spinal disease management, and radiotherapy.

Guideline presents an “important step forward for myeloma patients”

Professor Mark Baker, clinical practice director for NICE, said: “Although there is no cure for myeloma, several novel drug treatments have been licensed in the past 10 years that have led to substantial improvements in the quality and length of time it is possible to live with the disease. However, there is still variation across the country in terms of providing a coherent and consistent approach to the management of myeloma.

“Myeloma is also a difficult condition to diagnose because many of the symptoms are non-specific. Our guideline sets out best practice care to ensure people live as normal a life as possible for as long as possible.”

Alan Chant, patient and carer member of the guideline committee, said: “This guideline represents an important step forward for myeloma patients. As well as reinforcing existing best practice, it makes recommendations for treatment based on evidence and the experience of leading clinicians. It should ensure that diagnosis and treatment are standardised throughout the country.”