Introduction
Multiple myeloma is an incurable hematological malignancy in which clonal plasma cells proliferate in the bone marrow. Multiple myeloma is the second most common hematological malignancy. Worldwide, multiple myeloma accounts for about 13% of all hematological cancers [
1]. The incidence of multiple myeloma was estimated at 6.1 per 100,000 people per year [
2,
3].
It is well-established that multiple myeloma can cause significant osteolytic and osteoporotic bone disease [
4,
5]. In addition, multiple myeloma affects older adults, among whom, osteoporosis is also common [
6]. Therefore, bone disease is a major source of morbidity and mortality among patients with multiple myeloma [
5]. It has been suggested that osteolytic lesions develop as a result of increased osteoclastic resorption [
4,
5,
7]. Additionally, increased bone resorption results from the interaction between bone marrow stromal cells and myeloma tumor cells within the bone marrow microenvironment [
7]. Therefore, the overproduction of osteoclasts and reduced stimulation of osteoblasts leads to imbalanced bone turnover and increased risk of pathologic fractures [
8‐
10]. Stimulation of osteoclast-activating growth factors, cytokine release, and lack of osteoblastic response can lead to the development of destructive bone lesions and diffuse osteopenia [
4,
5,
7,
11]. The consequences of these osteolytic bone lesions can be severe for patients, causing fractures, severe bone pain, spinal cord compression, hypercalcemia, and renal insufficiency, all of which can have a devastating effect on the quality of life and worsen survival prospects for patients [
10,
12].
Previous studies have reported that the vast majority (about 85%) of patients with multiple myeloma develop bone disease [
7,
13]. It is well-established that lytic bone lesions are associated with fractures, poor mobility, pain, poor blood circulation, and incidence of blood clots. Therefore, hematologists-oncologists and other healthcare professionals caring for patients with multiple myeloma should address bone health while diagnosing, caring for, and following up with this particular group of patients.
Different professional groups and associations including the International Myeloma Working Group (IMWG) have developed consensus/evidence-based recommendations to guide assessing, managing, and monitoring bone health, pain, and mobility among patients with multiple myeloma [
5,
10,
14‐
17]. These recommendations can be used at varying points in the trajectory of the disease.
In Palestine, little is known about the adherence of the hematologists-oncologists to the consensus/evidence-based recommendations for assessing, managing, and monitoring bone health, pain, and mobility in patients with multiple myeloma. Therefore, this study was conducted to assess the adherence of the hematologists-oncologists to the consensus/evidence-based recommendations for assessing, managing, and monitoring bone health, pain, and mobility in patients with multiple myeloma who received care in the Palestinian healthcare system. The findings of this study might be informative to decision-makers and policymakers who might be interested in improving care for patients with multiple myeloma, maintaining bone health, reducing pain and other disabling symptoms, promoting mobility, and improving the health-related quality of life of the affected patients. The findings of this study might also apply to other healthcare systems in poor, underdeveloped, and resource-limited settings.
Discussion
Because of the increased risk of pathological fractures, caring for the bone health of patients with multiple myeloma is crucial [
4,
5]. Additionally, the different treatment modalities used to manage multiple myeloma like chemotherapy and glucocorticoids also increase the risk of bone fractures [
49]. Therefore, it is important to assess and manage the bone health of patients with multiple myeloma to prevent fractures, maintain their quality of life, and improve their overall health outcomes [
5,
10,
14‐
17]. In this study, adherence of the hematologists-oncologists to the consensus/evidence-based recommendations for assessing, managing, and monitoring bone health, pain, and mobility in patients with multiple myeloma who received care in the Palestinian healthcare system was assessed for the first time. Decision-makers and policymakers in the Palestinian healthcare system and those in other poor, developing, and resource-limited settings might benefit from the findings reported in this study to design measures and implement policies to increase adherence to the consensus-based guidelines and recommendations while caring for patients with multiple myeloma.
The findings of this study showed inadequate adherence to the recommended guidelines for diagnosing patients with multiple myeloma, particularly ordering and evaluating blood calcium levels and bone imaging to look for osteolytic lesions. It is worth noting that blood calcium levels and osteolytic lesions are important in the diagnosis of multiple myeloma as per the revised IMWG diagnostic criteria [
1,
10,
16,
29‐
36]. It is well-established that multiple myeloma is associated with hypercalcemia [
50]. Hypercalcemia is known to cause kidney disease, increase the risk of bone fractures, and decrease the effectiveness of certain chemotherapeutic agents. Despite advancements in diagnostic and therapeutic options, hypercalcemia remains an important adverse prognostic factor that should be considered while diagnosing new cases of multiple myeloma [
29‐
36,
38,
48,
50]. Because these tests are essential for accurately diagnosing and staging multiple myeloma, failure to perform these tests could lead to missed diagnoses and/or suboptimal treatment. In a previous study, the Poitou-Charentes cancer registry was used to assess adherence to the recommended guidelines for the diagnosis, staging, treatment, and prognosis of patients with multiple myeloma [
51]. Adherence to the recommended guidelines for diagnosing patients with multiple myeloma was 98%. In Palestine, caring for cancer patients has long been described as fragmented [
52,
53]. Lack of coordination between hematologists-oncologists, radiologists, pathologists, and surgeons was previously reported [
52]. The 5 centers where patients with multiple myeloma receive healthcare are small hematology/oncology units. These centers lack specialized pathology laboratories, imaging, and advanced diagnostic facilities. Currently, there is a need for a comprehensive care center offering all diagnostic, treatment, and care services to patients with multiple myeloma.
In this study, the hematologists-oncologists reported inadequate adherence to the recommended guidelines, notably monitoring and maintaining bone health. Because osteolytic lesions and fractures are very common among patients with multiple myeloma [
7,
13], hematologists-oncologists should periodically monitor and maintain bone health. This can be done by screening for medication problems, maintaining optimal calcium and vitamin D levels, prescribing bisphosphonates, and referring patients to orthopedic surgeons whenever needed. It is noteworthy to mention that multiple myeloma can comorbid with osteoporosis in older adults [
6]. Moreover, many of the medications used to treat multiple myeloma like corticosteroids can increase the risk of bone loss and fractures [
10,
54]. Similarly, optimal calcium and vitamin D levels should be maintained. In the absence of contraindications, bisphosphonates, calcium, and vitamin D supplements should be prescribed to patients with multiple myeloma [
10]. Moreover, the findings of this study have shown that there was inadequate adherence to assessing and managing pain. Pain is one of the most common and distressing symptoms experienced by patients with multiple myeloma [
55]. Multiple myeloma can cause bone pain, neuropathic pain, and pain associated with fractures, and pain can also be a side effect of treatment [
55,
56]. Uncontrolled pain can lead to decreased quality of life, decreased mobility, and increased risk of depression and anxiety [
56]. Therefore, it is recommended that healthcare providers assess and identify the type, severity, and location of pain, and develop an individualized pain management plan that can improve patient comfort and quality of life [
1]. Additionally, regular pain assessment can also help to detect new or worsening pain early, which may be a sign of disease progression or treatment side effects, allowing for timely intervention.
In this study, a lack of adherence to the recommended guidelines for the management of patients with multiple myeloma was also reported in several supportive areas, notably screening for fatigue, assessing cardiovascular and pulmonary fitness, assessing and supporting mobility, prescribing physical activity plans, screening for nutritional deficits, and maintaining the well-being of the patients. These findings were not surprising as psychosocial support, rehabilitation, palliative care, and nutritional services offered to cancer patients in the Palestinian healthcare system are substandard [
52]. Inadequate addressing of these issues can result in poor health outcomes, increased risk of complications, and deteriorate the quality of life of the patients [
1,
5,
10,
14,
16].
Strengths and limitations
The findings of this study should be interpreted after considering the following strengths and limitations. First, this was the first study to assess the extent of adherence to the recommended guidelines that should be used in the assessment and management of bone health, pain, and mobility in patients with multiple myeloma in the Palestinian healthcare system. The findings of this study might reflect those in the other healthcare systems of poor, underdeveloped, and resource-limited countries. Second, the study was inclusive of all healthcare centers where patients with multiple myeloma received healthcare in Palestine. Therefore, the findings of this study are reflective of those seen in the different centers. Third, a mixed method was used in this study. Mixed methods that combine qualitative and quantitative approaches are powerful in portraying the practices followed in the healthcare system.
On the other hand, the study had some limitations. First, the sample size used in this study was very small. It is noteworthy to mention that only 5 centers in the West Bank care for patients with multiple myeloma. However, instead of asking the head of the hematology/oncology department and a main hematologist-oncologist from each center to respond to the questionnaire, we could have asked all hematologists-oncologists to participate in the study. This might have reduced the potential selection bias in this study. Purposive sampling has long been criticized as biased. Second, the answers of the hematologists-oncologists were self-reported. Therefore, desirability and recall biases could not be excluded. Second, patients were not interviewed in this study. The inclusion of patients should have added more richness to the findings reported in this study. Third, the study was conducted among hematologists-oncologists, the inclusion of other healthcare providers might have also provided richness to the findings reported in this study. Fourth, the extent of awareness of the hematologists-oncologists of the existing guidelines should have been assessed in this study. In this study, the interview guide was based on the IMWG guidelines. Furthermore, more interview questions should have been included to explore the reasons for lack of adherence to the international guidelines. This should have provided more insights into the effects of the limited number of service providers, lack of coordination, and equipment on adherence to the international guidelines. Finally, the findings of this study cannot be generalized to the entire population of hematologists-oncologists providing care services to patients with multiple myeloma in the Palestinian healthcare system.
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