Potential for cancer related health services research using a linked Medicare-tumor registry database, Comparison of SEER treatment data with Medicare claims, Chronic medical illness, depression, and use of acute medical services among Medicare beneficiaries, Design challenges of an episode-based payment model in oncology: The Centers for Medicare & Medicaid Services Oncology Care Model, International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma, Multiple myeloma: 2016 update on diagnosis, risk-stratification, and management, Current depression as a potential barrier to health care utilization in adult cancer survivors, Living with multiple myeloma: a continuum-based approach to cancer survivorship, International Myeloma Foundation Nurse Leadership Board, Survivorship care guidelines for patients living with multiple myeloma: consensus statements of the International Myeloma Foundation Nurse Leadership Board, Providing psychiatric care for an expanding population of cancer survivors: imperatives for psychiatric education and leadership, Four-week prevalence of mental disorders in patients with cancer across major tumor entities, The prevalence of psychological distress by cancer site, Prevalence of symptoms in patients with multiple myeloma: a systematic review and meta-analysis, Prevalence of depression and anxiety in older patients with multiple myeloma in North Carolina: a population-based, claims-based assessment, The impact of depression and use of anti-depressants on Healthcare Resource Utilization (HCRU) in multiple myeloma (MM) patients, Anti-depressant use in patients with multiple myeloma less common than expected. Pediatr Phys Ther. Refer to the study protocol for further information about the guideline development process.7. Accordingly, the statements were revised based on the feedback from the physical therapists. At the same time, the presence of advanced MM with complications could give rise to psychiatric comorbidities, because we noted a higher incidence of clinical MDEs in patients with incident psychiatric conditions after MM diagnosis. Neal J, Shahpar S, Spill G, Semik P, Marciniak C. The Leukemia/Bone Marrow Transplant Program of British Columbia. Bone marrow is the spongy tissue at the centre of some bones that produces the body's blood cells. Given the variation of the population for which the above guidelines are recommended, we suggest light resistance exercises using elastic bands if no signs of bleeding without strain for patients with MM with platelets between 20,000 and 40,000/μL. Multiple myeloma is a cancer that affects bone marrow cells called plasma cells. Before undergoing medical therapy may be the most opportune time to increase aerobic capacity and strength, thereby aiding with the impending deconditioning and recovery process. These findings need to be addressed for improved survivorship of MM patients. When the synapses cannot communicate properly, the brain and body cannot function properly. MM patients diagnosed between 1991 and 2010 and reported in the Surveillance Epidemiology, and End Results-Medicare database were characterized as MM-Only, MM+Psychiatric (any psychiatric condition, preexisting or post-MM), or MM+Depression (depression as the only psychiatric diagnosis, preexisting or post-MM). There are . All of the separate analyses were significant (P < 0.001), with the exception of that for outpatient care cost between MM-Only and MM+Depression groups (multivariate odds ratio, 1.05; 95% CI, 0.99-1.11; P = .123). de Almeida LB, Trevizan PF, Laterza MC, Hallack Neto AE, Perrone ACASJ, Martinez DG. 3, 5c, and 4b) received 78% consensus to include, and 1 item (item no. Can diet and exercise reverse prediabetes? This increase in cost was more pronounced for patients from racial minorities diagnosed with a psychiatric condition, including depression. Similar to the MM+Psychiatric group analysis, whites were the most numerous race overall (72.4%) followed by African Americans (15.3%), Hispanics (7.6%), Asians (4.4%) and others (0.3%), but again, the racial distribution of patients with depression was significantly different (P < .001) with 30% whites, 27% African Americans, 25% Hispanics, and only 18% Asians in the MM+Depression group. doi: https://doi.org/10.1182/bloodadvances.2018016717. Present in up to 60-70% of people and may have pre-existed for months. Furthermore, we compared patients who were diagnosed with any psychiatric condition within 12 months prior to or 6 months after receiving the diagnosis of MM. Rosenfeldt A, Pilkey LM, Butler RS. Produced in bone marrow, these are an essential first…, Multiple myeloma is a type of blood cancer that affects plasma cells. We link primary sources — including studies, scientific references, and statistics — within each article and also list them in the resources section at the bottom of our articles. Stage 3 multiple myeloma: Symptoms, progression, and life expectancy. MGUS is where there is an excess of protein molecules, called immunoglobulins, in your blood. Is mental confusion a sign of multiple myeloma? Blood Adv 2018; 2 (10): 1120–1128. This could be secondary to the negative effects of certain psychiatric medications on physiological aspects of the patient, including bone density and hematopoiesis.34,35 Although we did not assess medication compliance, it is possible that the development of psychiatric comorbidities after the MM diagnosis could lead to behavioral factors resulting in poor compliance with anti-MM treatment, leading to more organ damage and poor MM control. Hacker ED, Collins E, Park C, Peters T, Patel P, Rondelli D. Guyatt GH, Oxman AD, Vist GE, et al. V.R. Preferred Reporting Items for Systematic Reviews (PRISMA) flow diagram. This is an Open Access article distributed under the terms of the Creative Commons Attribution NonCommercial-NoDerivs licence (. Hypercalcemia is a serious complication. through a college of physiotherapy public registry. There have been substantial improvements in management strategies for MM, resulting in declining death rates.1-3 With these advances, the focus is moving to chronic and comorbid health issues that may affect patient quality of life, general well-being, and survivorship among MM patients.24,25 An important component of survivorship is psychosocial well-being. Autopsy-only cases were excluded. Multiple studies met the criteria for inclusion.30–32 These programs utilized a combination of high- or low-intensity exercise with both supervised and/or unsupervised sessions to understand the impact on psychosocial well-being. Read more about treating multiple myeloma. Hung YC, Bauer JD, Horsely P, Coll J, Bashford J, Isenring EA. The abnormal proteins can also cause inflammation in the kidneys. Patients with multiple myeloma (MM) may experience anemia, thrombocytopenia, pancytopenia or neutropenia, bony lesions, or fractures at some point due to the cancer itself or as a direct side effect of cancer treatments.1 Patients with this presentation are typically admitted to hospitals for supportive treatments such as high-dose chemotherapy, autologous stem cell transplantation, antibiotics, blood transfusions, radiation therapy, and surgical interventions for pathologic and impending fractures. Multiple myeloma can cause mental confusion for a variety of reasons. Although some initial data are available,15,16 appropriately powered studies, especially across specific cancer types, are lacking. Because of small numbers, Native Americans were not included separately in the statistical analysis. Oxford University Press is a department of the University of Oxford. Physical therapists should assess their own practice environment and use their clinical skills to implement the AS based on patients’ needs. Cost of cancer care has increased considerably over time and is projected to increase much more in the future.11-14 Although novel therapeutic agents are considered the major cause of the increasing cost of cancer care, studies have also shown that caring for cancer patients with depression and other psychiatric conditions is associated with significantly higher cost and increased health care utilization.15,16 Due to the overlap of cancer diagnosis, near universal utilization of systemic steroids for prolonged periods of time, and an older population with frequent comorbidities, MM is a uniquely suited population for studying the impact of psychiatric conditions on cost of care and health care utilization. Interestingly, these authors also report that platelet count is an imprecise predictor of bleeding risk. As such, a limited number of articles reported physical outcomes of mixed exercise programs for patients with MM before,24 during,5,25–30 and after medical therapy.30–32. In addition, Mohammed et al44 conducted a literature review and developed a protocol for patients undergoing hematopoietic stem cell transplantation, and it supports the recommendations proposed by our group. These shortages can lead to other symptoms. There are no specific exercise recommendations for patients with leukopenia and neutropenia; therefore, we recommend the following for physical therapy in this population to prevent infection. The guideline development steps recommended by the American Physical Therapy Association were followed when drafting recommendations and determining levels of evidence.33 Recommendations for research questions with inadequate evidence were developed based on a consensus process.34 Recommendations were made in the form of action statements (AS), and levels of evidence and grades of AS were determined using the recommendations of Kaplan and colleagues.35 Tables 1 and 2 outline the levels of evidence and grades of recommendations. While bed rest is important in preventing bleeding, multiple weeks of bed rest may cause significant functional decline in older patients with MM. Osteoporosis is when a person has fragile, low-density bones that break easily. Multiple Myeloma (MM) is a deadly blood cancer that often infiltrates the bone marrow causing anemia, kidney failure, immune problems, and bone fractures. However, given the benefits described above, along with a low risk of harm to the patient, the results suggest that clinicians may prescribe exercise to reduce sleep, fatigue, and QOL issues, pending individualized considerations are met. There is not a low limit cut-off for suspending all physical activity in patients with thrombocytopenia, particularly in patients undergoing chemotherapy.14 The Leukemia/Bone Marrow Transplant Program of British Columbia (L/BMT program of BC) recommends limited physical activity when platelet counts are <15,000/μL; however, Sekhon and Roy13 reported risk of bleeding with counts <10,000/μL. Shehzad Niazi, Ryan D. Frank, Mayank Sharma, Vivek Roy, Steve Ames, Teresa Rummans, Aaron Spaulding, Taimur Sher, Meghna Ailawadhi, Kirtipal Bhatia, Salman Ahmed, Winston Tan, Asher Chanan-Khan, Sikander Ailawadhi; Impact of psychiatric comorbidities on health care utilization and cost of care in multiple myeloma. Selected baseline characteristics for all patients included in the analysis are summarized in Table 1. A higher number of females (52.7%) had preexisting psychiatric conditions, whereas more males (51.5%) were diagnosed with any psychiatric disorder after MM (P < .001). The consensus process was conducted in 2 phases. P < .001; adjusted for age, calendar year, sex, race, and CCI. Differences in demographic characteristics, occurrence of clinical myeloma-defining events (MDEs), health care utilization (inpatient, outpatient, ambulatory claims), and cost of care during the first 6 months of MM diagnosis were analyzed. The same adjustment terms described previously were used in the multivariate models. 3). They can diagnose the cause and prescribe the appropriate treatment. During the first 6 months of treatment after MM diagnosis, MM+Psychiatric patients had a median cost of care of $18 700 compared with $12 300 for MM-Only patients (multivariate odds ratio, 1.25; 95% CI, 1.20-1.31, P < .001). Bone marrow is the spongy tissue at the centre of some bones that produces the body's blood cells. This is called hyperviscosity. Those with preexisting depression were older (median, 77 years; IQR, 71-82) compared with patients with depression diagnosed after MM (median, 75 years; IQR 69-80; P < .001). 4c, 4d, 4e, 5b, 7, 8, 8d, 9, 9a, 9b, 9c, 9d, 10, 10a, 10b, and 10c) received 100% consensus to include, 9 items (item nos. In rare cases, hyperviscosity may cause stroke-like symptoms. Furthermore, this guideline was reviewed and rated by methodologists with clinical and research experience in oncology. Cost of care within the first 6 months after MM diagnosis was significantly higher in the MM+Psychiatric and MM+Depression groups. Because white blood cells protect the body from harmful germs, someone with leukopenia has a lower resistance to infections. A combination of systematic review, critical appraisal, and expert opinion was used for guideline development. In terms of strength, all patients experienced a decline from baseline, but those who exercised had a less severe decline. Similar to our analysis in MM patients, Han et al noted a greater impact on health care utilization and expenditures in the inpatient and emergency care settings compared with ambulatory care for all cancer patients.15 They noted significantly increased medical expenditures in cancer survivors with serious psychological distress compared with cancer survivors or noncancer patients without such distress.15 However, compared with our analysis, their study included a much smaller number of cancer patients and did not focus on a single cancer diagnosis. The focus group recommended rewording some sentences and including additional precautions for a few of the items. A 2020 study of people under 65 with multiple myeloma found that the people with hypercalcemia had lower survival rates than those who did not. Conflict-of-interest disclosure: The authors declare no competing financial interests. (B) Total cost of care during the first 6 months after MM diagnosis for patients with any psychiatric condition (MM+Psychiatric) vs no psychiatric condition (MM-Only) (upper panel) and for patients with depression (MM+Depression) vs no depression (MM-Only) by patient race (white, Hispanic, African American, and Asian). People with anemia may have weakness, dizziness, and shortness of breath. Multiple myeloma ( MM ), also known as plasma cell myeloma and simply myeloma, is a cancer of plasma cells, a type of white blood cell that normally produces antibodies. (2019). Of these, 4 physical therapists were from Ontario, 2 from Winnipeg, 2 from Québec, and 1 from British Columbia and 1 from Alberta. Neutropenia is often present in patients with MM and is an expected side effect following chemotherapy. Physical therapist intervention is generally contraindicated in patients with hemoglobin values less than 8 g/dL.9 It is recommended to take precautionary measures but not to withhold physical therapy for patients with hemoglobin levels lower than 8 g/dL.9 Evidence shows that patients with levels as low as 7 g/dL (HgB level) can tolerate physiotherapy, but those patients with cardiac and respiratory conditions are at a higher risk of compromised cardiac output and desaturation.10 Stiller and Phillips11 recommend withholding mobilization for patients with levels lower than 7 g/dL. Hector Roqueta Rivero/Getty Images. It's not known exactly what causes multiple myeloma. Hypercalcemia is a condition where an individual elevated calcium levels in their blood. 6) received only 67% consensus to include. Univariate and multivariate logistic regression models (adjusted for age, year, sex, race, and CCI) were performed to determine whether there were associations among patients in each of the diagnosis groups and health care claims (inpatient, ambulatory, emergency). It's called multiple myeloma as the cancer often affects several areas of the body, such as the spine, skull, pelvis and ribs. Any medical information published on this website is not intended as a substitute for informed medical advice and you should not take any action before consulting with a healthcare professional. Of note, these articles were not included in the current guideline development process but will be included in the 2025 guideline update. Thus, the objectives of this study were to (1) develop a set of consensus-based recommendations to help physical therapists make decisions on mobilization and exercise intervention of patients with MM in acute care settings, particularly based on laboratory values (hemoglobin, platelet, and white blood cell counts) and bony lesions; and (2) develop evidence-based recommendations for physical therapy management before, during, and after chemotherapy and stem cell transplantation to improve strength, endurance, functional mobility, fatigue, increased nighttime sleep, and QOL in patients with MM. It can cause mental confusion in some people. This same study also reported fatigue in nearly 99%, pain in 59%, and neuropathy symptoms in 53% of patients with MM.29 These chronic comorbidities could be a part of a psychosomatic symptom complex, with interplay among the effects of the underlying malignancy, its treatment, and preexisting or incident psychiatric conditions. A quick scoping review was conducted in June 2020 by 1 of the original investigators (Z.M.) Completed in 2 parts: The initial draft AS were developed by 2 experienced oncology/hematology physical therapists after reviewing supporting articles and guidelines (AS1–6). With the exception of anemia, all other clinical MDEs were seen in a significantly higher proportion of patients with a psychiatric diagnosis after MM rather than those with preexisting psychiatric diagnoses (P < .001) (Table 2). This becomes significant, considering the strain on the current health care system in view of the population increase, improved survival, and longevity from cancer diagnoses in general and an increasingly diverse patient population with variable diagnostic and management challenges. The GENESIS trial enrolled 122 people with multiple myeloma, ranging from 18 - 78 years old. Our research team decided to eliminate 1 AS (acupuncture for pain relief during or after medical treatment) during the first round because the majority of the physical therapists reported that they did not have expertise in acupuncture treatment. ), as outlined in the study protocol, to understand the research evidence around the physical therapy management of MM.7 In brief, a reviewer (Z.M.) Patients with multiple myeloma (MM) may experience anemia, thrombocytopenia, pancytopenia or neutropenia, bony lesions, or fractures at some point due to the cancer itself or as a direct side effect of cancer treatments. There was a significant difference in sex distribution between the 2 groups with majority (54.5%) of MM-Only patients being males while 57.3% of MM+Depression patients being females (P < .001). (2021). Although initially, an individual may have no symptoms, they can appear over time. As expected, all patients typically experienced declines in physical performance, yet the trends suggest that exercise, if adhered to, reduces this impact, allowing patients to maintain close to baseline scores.5,29,30 Specifically, these programs may allow for an increase in aerobic capacity and muscular strength compared with usual care27 and, not surprisingly, support a higher rating of good overall condition, more physical activity, and better integration into daily life. Our special thanks to the Canadian Physiotherapy Association and the Program in Evidence Based Care, McMaster University, and Dr Sathish Kumar Gopalakrishnan, Hematologist at Health Sciences North, for providing feedback. Median age for both groups was 76 years (IQR, 70-82). Trial participants were randomly assigned to receive G-CSF plus motixafortide or G-CSF plus a placebo for stem cell mobilization. Patients in the MM+Psychiatric and MM+Depression groups had higher costs of care than MM-Only patients (Table 4; Figure 2A). In the first round, 16 items (item nos. It causes these cells to grow too much, crowding out healthy blood cells and damaging bone tissue. The racial distribution of patients with any psychiatric comorbidity was significantly different (P < .001), with 43% of whites, 44% of African Americans, 38% of Hispanics, and 29% of Asians in the MM+Psychiatric group. [1] [2] It is usually associated with osteolytic bone disease, anaemia, and . The results of the studies above highlight the importance of exercise during and after medical therapy to positively influence the mental well-being of the patient. These mixed, individualized exercise programs may create a stronger physical base prior to treatment and reduce the impact during the deconditioning phase, possibly reducing recovery time. Association of cost of care with psychiatric conditions during the first 6 months of care after MM diagnosis in various health care settings. Multiple myeloma (MM) is the second most common hematologic malignancy, with ∼30 000 new patients diagnosed annually.1 Management of MM has significantly improved over recent years, with better outcomes.2,3 With increased survival, many patients would experience common psychiatric issues that occur in up to 25% of cancer patients.4-6 MM patients have several factors that increase their risk for psychiatric diagnoses, including the median age at diagnosis (69 years), when other coexisting comorbidities can contribute to psychiatric conditions.1,7,8 Furthermore, nearly all MM patients are prescribed long-term systemic steroids, which are reported to cause a number of neuropsychiatric effects, including mood symptoms, psychosis, delirium, cognitive impairment, and sleep disorders, in nearly 60% of patients receiving them.4,9,10 To date, studies have not systematically explored the health care impact of psychiatric comorbidities among MM patients. Patients with MM typically receive a transfusion of red blood cells (RBC) when the Hb concentration is lower than 7 g/dL in stable adults or lower than 8 g/dL in those with cardiac issues. Although doctors do not know what causes MM, a person's genetics may contribute to their risk of developing it.. Can diet help improve depression symptoms? Although it is known that psychiatric comorbidities, especially depression, can lead to other somatic symptoms, the increased incidence of physical signs is very significant. Further, those with skeletal issues can still exercise but may require supervision and motivation to follow through with any program. Patients may receive a transfusion for approximately 2 to several hours depending on the number of units of RBCs. A literature search strategy was developed and performed by 2 research assistants (M.L. A total of 30 action statements were developed that achieved consensus, indicating physical therapy recommendations based on physiological markers (ie, hemoglobin, platelet count), complete patient presentation, and the stage of medical treatment. The clinically important trends highlighted that more patients had maintenance of body composition and higher rate of weekly physical activity, again with aerobic training (walking) as a preference. We also assessed any associations between the cost of care (total Medicare claims) during the first 6 months after MM diagnosis and patient race. Further, it was identified that patients with skeletal issues can exercise safely but may ultimately require supervision and thoughtful modifications to their exercise regimen. Address all correspondence to Dr. Jeevanantham at: Search for other works by this author on: Fatigue and physical activity in patients undergoing hematopoietic stem cell transplant, Recommended exercise protocol to decrease cancer-related fatigue and muscle wasting in patients with multiple myeloma, The influence of daytime inactivity and nighttime restlessness on cancer-related fatigue, Effects of exercise on fatigue, sleep, and performance: a randomized trial, Quality of life changes following peripheral blood stem cell transplantation and participation in a mixed-type, moderate-intensity, exercise program, Evidence-based guidelines for physiotherapy management of patients with multiple myeloma: study protocol, AGREE II: advancing guideline development, reporting and evaluation in healthcare, The impact of low hemoglobin on the percentage of adverse events during physical therapy in the acute care setting, The CRIT study: Anemia and blood transfusion in the critically ill--current clinical practice in the United States, Safety aspects of mobilising acutely ill inpatients, Physical therapy intervention during a red blood cell transfusion in an oncologic population: a preliminary study, Thrombocytopenia in adults: a practical approach to evaluation and management, Thrombocytopenia and physical activity among older adults: the tenuous line between bleeding prevention physical functional decline, Exercise and blood value precautions 2014, Bleeding events in thrombocytopenic patients with cancer undergoing acute rehabilitation, The Leukemia/Bone Marrow Transplant Program of British Columbia, British Columbia: Leukemia/Bone Marrow Transplant Program of British Columbia, Infections in patients with multiple myeloma in the era of high-dose therapy and novel agents, EORTC quality of life group. During treatment, these patients will typically become inpatients, and supervised exercise or rehabilitation may be implemented at this time. Of the 119 patients, 49 had hematologic cancer and there were 56 bleeding events. Initially, an individual may not know they have MM, and a doctor only discovers it following a routine blood or urine test. Learn more about these factors here. This doesn't cause any symptoms and doesn't need treatment. These conditions developing within the first 30 days after MM diagnosis were not included because it could not be determined whether they were related to MM or acute adverse events from the antimyeloma treatment or were potentially preexisting and independent and were diagnosed simultaneously with the MM. The Creative Commons license does not apply to this table. These can include slurred speech and weakness on one side of the body. Contribution: S.N., R.D.F., and S. Ames were involved in study design; S. Ailawadhi was involved in data collection; S.N., R.D.F., V.R., S. Ahmed, T.R., A.S., T.S., and W.T. Approximately one third of cancer patients suffer from comorbid mood disorders that are associated with increased cost and poorer outcomes. We recommend that the following strategies be implemented in practice: (1) keep a copy of these guidelines at your practice; (2) share these guidelines with your peers (physical therapists) and patients, and with the physicians, oncologists, and hematologist of your patients who are interested in learning about physical therapy for MM; and (3) build relationships with referral sources to encourage early referrals of patients with MM. systematically searched databases and retrieved 48,060 articles with EndNote software, and 28,679 articles were recovered after removing duplicates. Although asymptomatic neutropenia is not a medical emergency, neutropenia increases the risk of infection.18 Febrile neutropenia is an oncologic medical emergency, and patients with febrile neutropenia are often hospitalized for treatment. Shallwani S, Dalzell MA, Sateren W, O'Brien S. Oechsle K, Aslan Z, Suesse Y, Jensen W, Bokemeyer C, de Wit M. Coleman EA, Coon S, Hall-Barrow J, Richards K, Gaylor D, Stewart B. Coleman EA, Coon SK, Kennedy RL, et al. Certain treatments for MM can also cause mental confusion in some people. Corwin HL, Gettinger A, Pearl RG, et al. This study was reviewed and funded by the Northern Ontario Academic Medicine Association (Project C-17-11). Of the 36 007 patients included in the analysis, 15 168 (42.1%) were in the MM+Psychiatric group, and 20 839 were in the MM-Only group. Because depression was the most common psychiatric condition noted in our dataset, it was considered separately in our analysis. were involved in data analysis; S.N., R.D.F., M.S., M.A., K.B., S. Ahmed, A.C.-K., and S. Ailawadhi wrote the manuscript; and the final manuscript was reviewed and approved by all authors. Please contact permissions@lww.com for further information. Instead, it damages the bones and affects the production of healthy blood cells. Indeed, MM is a representative cancer diagnosis, with >90% patients treated with long-term systemic steroids, possibly the highest utilization of steroids in any cancer diagnosis.9,10 One study specifically looking at the prevalence of various symptoms in patients with MM reported depression in 23.4% of patients and anxiety in 35.7% of patients.29 Other, not yet published analyses have reported the prevalence of depression and anxiety in MM patients ranging from 14% to 37%.30-32 This was significantly less than our study and could be secondary to a smaller sample size in that study, as well as ours being a population-based study, which is more representative of the true prevalence.