An Institutional Retrospective Study on Recognizing the Delay in Multiple Myeloma Diagnosis
Authors: Ghalehsari Nima , Kancharla Pragnan , Nimkar Neil S , Mazloom Anita , Ashraf Farah , Singh Angelica , Goldfinger Mendel 
Published: November 2019

Background
Multiple myeloma (MM) is the abnormal proliferation of plasma cells in the bone marrow often resulting in debilitating symptoms ranging from ostealgia to pathological fractures from bone destruction. According to American Cancer Society, MM accounts for 1-2% of cancers and approximately 17% of hematological malignancies in the United States each year (1). Fifty percent of patients with symptomatic MM have three or more primary care visits before they are referred to a specialist, which is greater than any other cancer (5). It has been shown that a delay in diagnosing multiple myeloma negatively impacts the clinical course of the disease and hence the outcome in patients (2). Patients with longer diagnostic intervals also experience shorter disease free survival and more complications from treatment (4). Herein, a retrospective analysis was performed to determine the average delay in diagnosis of MM.
Methods
This is a retrospective electronic chart review of all indexed newly diagnosed MM cases between 1/1/2014 through 12/31/2018 at New York-Presbyterian Brooklyn Methodist Hospital (NYP BHM). NYP BMH is a Weill Cornell Medical College-affiliated hospital in Brooklyn, NY whose patient population includes those with private insurance, uninsured and Medicare/Medicaid. Data abstraction from the electronic medical record (EMR) was uniform and involved baseline characteristics such as age, gender and race. International Classification of Diseases (ICD)-10-CM code (C90.00) was used for extraction of data which identified 492 patients. After excluding patients with MGUS or a prior diagnosis of multiple myeloma, 104 patients were included in the final study.
We calculated the number of days between the date of first abnormal laboratory value seen on bloodwork for a myeloma related sign (at least 90 days prior to diagnosis) to the date of bone marrow biopsy that confirmed the diagnosis. The inclusion criteria were anemia defined as hemoglobin &lt;12gm/dl, Hypercalcemia defined by corrected calcium &gt;10, kidney dysfunction with a creatinine &gt;1.5 and total protein &gt;8.
Results
Of the 104 patients with newly diagnosed MM, 69 patients were diagnosed within 90 days of the first abnormal lab value recorded in our electronic medical record (EMR). Thirty-five patients (34%) had a delay in diagnosis at least 90 days with a mean delay of 38 months. Isolated anemia was the most common abnormal lab finding with 29/104 (28%) having documented anemia at least 90 days prior to diagnosis of myeloma. The mean delay in diagnosis for patients with anemia was 41 months.
There were four patients with anemia and elevated creatinine with an average delay of 23 months. Five patients had anemia and elevated calcium with an average delay of 21 months. Nine patients had anemia and elevated total protein with an average delay of 38 months.
Conclusion:
In the current era where we have effective therapies for MM it is now more important than ever to avoid a delay in diagnosis. We demonstrate that 34% of patients receiving care at an Urban Teaching Hospital had at least a 90 day delay in their diagnosis of MM. Our cohort consisted of 64% African Americans, suggesting that minorities are more commonly affected by this. There is a need for more awareness amongst clinicians to consider the diagnosis of MM in the workup of anemia.
References:
1. Kariyawasan, C. C., D. A. Hughes, M. M. Jayatillake, and A. B. Mehta. 2007. "Multiple Myeloma: Causes and Consequences of Delay in Diagnosis." QJM: Monthly Journal of the Association of Physicians 100 (10): 635-40.
2. Siegel, Rebecca L., Kimberly D. Miller, and Ahmedin Jemal. 2019. "Cancer Statistics, 2019." CA: A Cancer Journal for Clinicians. https://doi.org/10.3322/caac.21551.
3. Vélez R, Turesson I, Landgren O, Kristinsson SY, Cuzick J. Incidence of multiple myeloma in Great Britain, Sweden, and Malmö, Sweden: the impact of differences in case ascertainment on observed incidence trends. BMJ Open. 2016;6:e009584.
4. Kariyawasan CC, Hughes DA, Jayatillake MM, et al. Multiple myeloma: causes and consequences of delay in diagnosis. QJM 2007;100:635-40. 10.1093/qjmed/hcm077
5. Lyratzopoulos G, Neal RD, Barbiere JM, et al. Variation in number of general practitioner consultations before hospital referral for cancer: findings from the 2010 National Cancer Patient Experience Survey in England. Lancet Oncol 2012;13:353-65. 10.1016/S1470-2045(12)70041-4

Disclosures
No relevant conflicts of interest to declare.