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 Table of Contents  
Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 101-106

Health-related quality of life in multiple myeloma in Kurdistan Iraq

1 Department of Pathology, College of Medicine, University of Duhok, Duhok, Iraq
2 Department of Medicine, College of Medicine, Hawler Medical University, Erbil, Iraq
3 Department of Haematology, Ministry of Health, Hiwa Cancer Hospital, Sulaymaniyah, Kurdistan Region, Iraq
4 Department of Pathology, College of Medicine, Hawler Medical University, Erbil, Iraq
5 Department of Medicine, College of Medicine, University of Duhok, Duhok, Iraq
6 Department of Pathology, College of Medicine, University of Sulaimani, Sulaymaniyah, Kurdistan Region, Iraq
7 Department of Haematology, Nanakali Hospital, Erbil, Iraq

Date of Submission03-May-2020
Date of Acceptance22-Jun-2020
Date of Web Publication10-Nov-2020

Correspondence Address:
Dr. Ameer I. A. Badi
Azadi Teaching Hospital Road, Duhok
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijh.ijh_22_20

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BACKGROUND: Health-related quality of life (HRQoL) in multiple myeloma (MM) gained increasing importance to ensure that the improved survival is associated with improved life quality.
OBJECTIVES: The aim of this study was to assess the HRQoL in a cohort of myeloma patients from Kurdistan region in Iraq.
MATERIALS AND METHODS: This observational, cross-sectional, multi-center study enrolled 138 patients with symptomatic MM patients. The patients' records were retrieved and they were also clinically assessed and appropriately investigated at the time of enrolment. HRQoL was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Multiple Myeloma module (EROTC QLQ-MY20.
RESULTS: The 138 patients included had a mean age of 60.4 years and included 83 males and 55 females. Significant predictors of worse HRQoL disease symptoms and side effects of treatment domains included increasing age, female sex, and increase number of treatment courses. Other predictors associated with worse disease symptom domain include presence of bone lesions and nonsecretory myeloma versus light chain myeloma. Basic parameters including the concentration of monoclonal band, hemoglobin, serum creatinine, calcium, and albumin were not significant associated with scores in any of the domain while serum LDH was associated with worse side effects of treatment scores. Furthermore, it was noted that patients who had underwent autologous stem cell transplants had better HRQoL in all domains compared to other modalities of therapy, though this did not reach significance.
CONCLUSIONS: HRQoL in MM treated in Iraqi Kurdistan is not much different from their Western counterparts and several predictors of worse QoL were identified in this cohort of patients.

Keywords: Health-related quality of life, multiple myeloma, quality of life questionnaire-multiple myeloma module

How to cite this article:
Badi AI, Al-Allawi NA, Yassin AK, Safar BM, Abdulla BK, Shamoon RP, Amin TA, Mohamed ZA, Mohammed AI, Hussein DJ, Hasan KM, Mohammed NS, Rajab RN, Hiwaizi F, Karim KJ, Hassan AM, Getta HA, Khoshnaw NS, Jalal SD, Mohammed AM, Abdullah DA. Health-related quality of life in multiple myeloma in Kurdistan Iraq. Iraqi J Hematol 2020;9:101-6

How to cite this URL:
Badi AI, Al-Allawi NA, Yassin AK, Safar BM, Abdulla BK, Shamoon RP, Amin TA, Mohamed ZA, Mohammed AI, Hussein DJ, Hasan KM, Mohammed NS, Rajab RN, Hiwaizi F, Karim KJ, Hassan AM, Getta HA, Khoshnaw NS, Jalal SD, Mohammed AM, Abdullah DA. Health-related quality of life in multiple myeloma in Kurdistan Iraq. Iraqi J Hematol [serial online] 2020 [cited 2021 Jun 14];9:101-6. Available from: https://www.ijhonline.org/text.asp?2020/9/2/101/300410

  Introduction Top

Health-related quality of life (HRQoL) have recently gained widespread attention in the assessment of patients' perspective toward their management and treatment options in a multitude of hematological disorders.[1] They are also gained importance in the process of new drugs approvals in these disorders.[2] Multiple myeloma (MM) is a bone marrow-based multifocal plasma cell neoplasm, usually associated with an M-protein in serum and/or urine.[3] It is essentially an incurable malignancy, though its prognosis has improved markedly over the past 20 years as new treatment options continue to be introduced.[4]

The current therapy protocols of newly diagnosed plasma cell myeloma involves induction treatment with repeated cycles of two or more drug combinations followed in legible patients by autologous stem cell transplant.[5],[6] However, eventually, the disease will progress or relapse, and initiation of a rescue treatment will be necessary.[7] Different therapeutic modalities cause a multitude of adverse effects which may have an impact on the patients' quality of life.[4],[8],[9],[10] Treatment in MM is complex and involves several factors such as disease stage, prognostic risk stratification, and severity of myeloma symptoms and complications.[7],[11],[12],[13]

MM is a frequently encountered hematological malignancy in Iraq with a multitude of the management options available. No study has addressed the HRQoL in this disease in our region. Thus, the current study had been initiated to tackle such paucity.

  Subjects and Methods Top

A total of 138 patients diagnosed with MM and visiting the three main hematology/oncology centers in Iraqi Kurdistan (Hiwa Hospital-Sulemiani, Azadi hospital-Duhok and Nana Kelly Hospital in Erbil) were available for inclusion in this cross-sectional study. The patients records were retrieved and their clinical, radiological, and laboratory data at diagnosis were recorded. The patients were assessed clinically, and various laboratory investigations were performed at the time of enrollment. Furthermore, the treatment protocols were reviewed in detail in each, and the current therapy was recorded. The original diagnosis of Myeloma was based on the WHO criteria which is basically marrow plasma cells in excess of 10% with evidence of organ damage (hypercalcemia, increased creatinine, bone lesions, and anemia).[3]

Myeloma-specific HRQoL instrument namely the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Multiple Myeloma module (EORTC QLQ-MY20) was used in all patients. This questionnaire has been validated, and is recommended as a MM disease specific instrument.[14] The module consists of 20 questions that cover four myeloma-specific HRQoL domains: Disease Symptoms, Side Effects of Treatment, Future Perspective, and Body Image. Three of these domains are multi-item scales: disease symptoms (includes bone aches or pain, back pain, hip pain, arm or shoulder pain, chest pain, and pain increasing with activity); side effects of treatment (includes drowsiness, thirst, feeling ill, dry mouth, hair loss, upset by hair loss, tingling hands or feet, restlessness/agitation, acid indigestion/heartburn, and burning or sore eyes); and future perspective (includes worry about death and health in the future, and thinking about illness). The body image scale, on the other hand, is a single-item scale that tackles physical attractiveness. Average of each of EROTC QLQ-MY20 domain scores is calculated, and transformed linearly to a score ranging from 0 to 100. A high score for Disease Symptoms and Side Effects of Treatment represents a high level of symptomatology or problems, whereas a high score for future perspective and body image represents better outcomes.

Informed consent was obtained from all recruited patients, and the study was approved by the ethical committee at the Kurdistan board of medical Specialties in Erbil, Iraq.

Statistical analysis utilized the Statistical Package for the Social Sciences (SPSS) (SPSS, Illinois, USA). Means (standard deviations) or range and medians were used as appropriate. Pearson correlations were used evaluate correlation between continuous variables, while Mann–Whitney U test and Kruskal Wallis test were used as non-parametric tests to determine associations, as appropriate. A P < 0.05 was considered statistically significant.

  Results Top

The age of the enrolled patients ranged from 35 to 89 years (mean 60.4 ± 11.5 years), and included 83 males and 55 females. [Table 1] shows the main characteristics of the enrollees at diagnosis.
Table 1: The main features of the 138 enrolled patients at diagnosis

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The HRQoL was evaluated in all 138 enrolled patients using EROTC QLQ-MY20 myeloma-specific instrument. The evaluation was done at a median of 24 months from diagnosis (range 1–106 months), and the numbers of therapy courses and current treatment received at the time of enrolment is presented in [Table 2]. The mean and standard deviation of each of the four domains of EROTC QLQ-MY20 instrument namely: disease symptoms, side effects of treatment, body image, and future perspectives are shown in [Table 3].
Table 2: The time since diagnosis, courses received and current therapy at the time of enrolment in 138 patients with myeloma

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Table 3: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Multiple Myeloma module scores at the time of enrolment of 138 patients with Myeloma

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Correlation between EROTC QLQ-MY20 domain scores and various continuous variables using Pearson correlation revealed that disease symptoms and side effects of treatment scores increased with increasing age and with number of treatment courses received, and these correlations were significant [Table 4]. Other significant correlations include a positive correlation between time since diagnosis and future perspective as well as LDH with side effects of treatment. Otherwise, none of the basic continuous parameters outlined in [Table 4] is correlated to any of the four domains of EROTC QLQ-MY20 instrument. Furthermore, it was found that females have higher disease symptoms scores compared to males, finding which was significant (P = 0.001), while there were no significant correlations with other domain scores. The presence of bone lesions was also associated with higher disease symptom scores (P = 0.009), but not with other domain scores. When the type of monoclonal immunoglobulin was assessed (IgG versus IgA), it was found that disease symptoms scores were higher in those with IgA, though it just failed to reach significance (P = 0.056). Moreover, a comparison between nonsecretory myeloma, light chain myeloma, and myelomas with serum monoclonal bands revealed that the highest disease symptom scores were in those with non-secretory myeloma and the least were in light chain myeloma, a finding which was significant (P = 0.045), while other domain scores were not significantly different. As shown in [Table 5], the mean ranks of the four domain scores relevant to modality of therapy at the time of enrollment, it is clear that the least disease symptoms and side effect scores were encountered in those who have underwent autologous stem cell therapy and are off therapy, while the highest ones are in those on IMiDs. Moreover, the highest scores for body image and future perspective were in those who had ASCT and are on no medication now. Overall, however, none of the variations was significant
Table 4: Pearson correlation Coefficients and Nonparametric P values of some of the major variables and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Multiple Myeloma module domain scores (significant P values are bold)

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Table 5: Mean Ranks of the four European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Multiple Myeloma module domains in each treatment Category at the time of the interview

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  Discussion Top

MM remains and despite the introduction of novel agents and a multitude of drug combinations an incurable disease. The main aim in the management is to prolong survival, delay progression, and deal with various complications by providing rather continuous therapy. This leads to an increasing role of health-related quality of life tools and scrutiny of their methodological aspects to ensure not only prolonged survival, but also a better quality of life and suitability of novel agents or drug combinations in management.[15]

The mean scores obtained for the disease symptoms domain of 28.4% in the current study were comparable to reports from some European countries of 23%–36.6%. The same could be also said of side effects of therapy domain score, where scores of 25.1% was observed, compared to 16.8%–30% in European countries. On the other hand, our rates for future perspectives of 66.8% are also similar to those in Western counterparts at 59.9%–73.3%. Body image scores were lower than some European reports of 77.9%–82.3%, but nearer to others of 63.3%.[16],[17],[18],[19] The overall similarities in the HRQoL results between our study and those of developed countries may be related to similarities in the clinical characteristics and treatment modalities used in Europe and our country.

The current study documented that disease symptoms and side effects of the treatment domains of HRQoL were correlated with age and that females fared worse than males. These finding has also been documented by previous studies including studies from various European countries, where symptoms tend to be more severe in older patients and in females as opposed to males.[16],[20],[21],[22]

The increase of disease symptoms and side effects of therapy scores with number of therapy of courses is expected, and has also been documented by previous studies including that of Despiegel et al., which demonstrated such an increase in disease symptoms and side effects of therapy in their study on cohort of routine clinical practice of French myeloma patients.[19]

Immunoglobulin A (IgA) myeloma is well known to be worse prognostically from IgG myeloma and is associated with worse cytogenetic categories [23] and it appears to be associated with worse quality of life in the current study, though it did not reach significance.

Myeloma bone disease is one of the most important complications of MM and is due to bone destruction and lack of bone formation mediated by several complex pathways, and it is a main cause of morbidity and disability in this disease.[24] Thus, the observation of significant association with worse quality of life as manifested by increased symptom disease domain scores is quite expected.

The observation that disease symptoms scores were significantly higher in NSM compared to secretory myelomas is likely to be related to the higher frequencies of renal insufficiency, bone lesions, and number of treatment courses received in the former patients. Studies on NSM are really scarce due to rarity of this entity, with contradictory observations regarding biological behavior and prognosis, and in the absence of monoclonal protein difficulties in monitoring as opposed to secretory myeloma.[25]

The observation that patients who were autologous stem cell transplant and are currently off therapy having a rather better quality of life than those receiving other forms of therapy, has been observed by earlier studies from Croatia and the Netherlands.[16],[26]

The limitations of the current study include it being a cross-sectional and not a longitudinal study. The latter type of study by following patients up and determining their quality of life through various period in their illness and various forms of therapy maybe more informative. Furthermore, the addition of EORTC QLQ C30 cancer HRQoL assessment to the specific Myeloma EORTC QLQ MY20 would have made the assessment more comprehensive.[19],[17]

  Conclusions Top

It appears that HRQoL in Myeloma patients treated by the three major Hematology/Oncology centers in Iraqi Kurdistan is not much different from their Western counterparts and that age, sex, number of treatment courses, bone disease, and the subtype of the Monoclonal band or its absence are predictors of this quality of Life. Future studies should be longitudinal and include more comprehensive HRQoL testing should be encouraged.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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