Palliative treatment of multiple myeloma patients with painful vertebral lesions: Preliminary results and experiences of a multicenter randomized controlled trial comparing patient reported outcomes at 4 weeks follow-up

Multiple myeloma, also known as bone marrow cancer, is a hematologic disease in the red bone marrow. It is associated with extensive expansion of cancer cells and affects the normal bone regeneration process, as it induces increased bone breakdown and prevents formation of new bone. These changes result in weakening of the bones, which leads to an increased risk of disease-induced fractures in the spine. Thus, 80% of patients with bone marrow cancer will experience fractures at some point in their lifetime. In recent decades, the medical treatment of bone marrow cancer has improved, which has led to a considerable extension of the expected survival time. However, patients with bone marrow cancer still suffer from painful fractures of the spine. This necessitates the exploration of new complementary treatment options to alleviate pain and improve daily functioning and quality of life for bone marrow cancer patients with painful spinal fractures. Percutaneous vertebroplasty (PVP) is a surgical procedure where bone cement is injected into the spinal fracture under local anesthesia. First, a small skin incision is made, and a cannula is then gradually inserted into the fractured vertebra under X-ray guidance. PVP aims to reduce pain caused by the spinal fracture and is considered a safe and effective treatment method for bone marrow patients with spinal fractures. However, scientific research in this area remains sparse and high-quality research results are lacking. Moreover, recent studies on the treatment of spinal fractures in patients with osteoporosis have cast doubt on the use of PVP in cancer treatment. Thus, the National Multiple Myeloma Project was designed to provide high-quality evidence on managing spinal fractures in patients with bone marrow cancer.

Study #1
In Study #1, we investigated if PVP could provide rapid pain relief for patients with bone marrow cancer and spinal fractures. We compared patient-reported questionnaires on back pain, daily functioning, and quality of life for two groups of bone marrow cancer patients 4 weeks after they were randomly assigned to either 1) standard medical pain care or 2) PVP in addition to standard medical pain care. The preliminary results indicate that PVP is a safe and effective treatment option for vertebral spinal fractures in patients with bone marrow cancer, as the group treated with PVP experienced significantly less pain and reported significantly higher daily functioning and quality of life 4 weeks after surgery than the group solely receiving standard pain care.

Study #2
In Study #2, we investigated healing time in two groups of patients receiving standard medical pain care for their spinal fractures: 1) patients with bone marrow cancer and 2) patients with osteoporosis. Four weeks after enrolment, patient-reported back pain scores were available for assessment for both groups. Our assessment showed that back pain scores at 4-weeks follow-up were significantly higher for patients with bone marrow cancer. This indicates that patients with bone marrow cancer and spinal fractures experience prolonged healing time.

Study #3
There can be multiple causes of spinal fractures, including osteoporosis and various cancer conditions, and the treatment of fractures depends on the underlying cause. Since timely initiation of relevant cancer treatment is crucial for patients with cancer-induced spinal fractures, it is necessary to distinguish between spinal fractures caused by cancer and osteoporosis. MRI scanning can be used for this purpose.

In Study #3, we investigated how effectively MRI scanning distinguishes between spinal fractures caused by cancer and osteoporosis after a new scanning sequence was added to the MRI scanning protocol in 2016. We did this by comparing MRI scan results made prior to PVP with biopsy diagnostics collected from the spinal fractures during the surgical procedure. Of the patients who underwent surgery for spinal fractures presumed to be due to osteoporosis, it was found that 0.9% were actually caused by cancer. We compared this proportion of unexpected cancer-related spinal fractures with a study from 2016 from the same department, which found 4.5% unexpected cancer-related spinal fractures. We thus concluded that MRI's ability to identify cancer-related spinal fractures was significantly improved after the addition of the new scanning sequence.