Intended for healthcare professionals

Practice Easily Missed?

Multiple myeloma

BMJ 2012; 344 doi: (Published 05 January 2012) Cite this as: BMJ 2012;344:d7953
  1. Danny C Hsu, university lecturer in medical education1, consultant haematologist2,
  2. Peter Wilkenfeld, primary care practitioner3,
  3. Douglas E Joshua, professor of medicine1, consultant haematologist2
  1. 1University of Sydney, Sydney, NSW 2050, Australia
  2. 2Institute of Haematology, Royal Prince Alfred Hospital, Sydney, Australia
  3. 3Bondi Junction, Sydney, NSW 2022, Australia
  1. Correspondence to: D C Hsu danny.hsu{at}

A 62 year old man presents to his general practitioner with new onset lower back pain and fatigue for the past few weeks. The patient denies any recent trauma and has otherwise been in good health except for a chest infection treated with oral amoxicillin three months ago. On examination there is midline tenderness over the L5 vertebra with no evidence of neurological signs. The general practitioner requests a full blood count, liver function tests, and a biochemistry panel, which showed mild normocytic normochromic anaemia with rouleaux in the blood film, mild renal impairment, and a raised total protein concentration. Serum electrophoresis confirms the presence of a monoclonal paraprotein. The general practitioner refers the patient to the haematology unit, where myeloma is diagnosed after further investigation and management.

What is multiple myeloma?

Multiple myeloma is a neoplasm of plasma cells characterised by the production of monoclonal immunoglobulin by the malignant cells. This disease predominantly affects older adults, and because of the protean manifestations of the disease patients can initially present to their primary care physicians with vague and confusing symptoms.

How common is multiple myeloma?

  • In the United Kingdom and the United States myeloma accounts for about 10% of all haematological malignancies1 2

  • The reported annual incidence of myeloma in the UK and the US is about 3-4 per 100 0003

  • The incidence of myeloma varies across different ethnic groups; in the US the incidence is twice as high in African Americans as in white people4 but in ethnic Chinese people in Taiwan it is as low as 0.75 per 100 0005

Why is multiple myeloma missed?

In a small retrospective UK case review more than half of symptomatic patients who had initially presented to their general practitioners had a delay of more than six months (>12 months in 33% of cases) before specialist referral.6 A large retrospective review of data …

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