The Most Common Causes of Late Diagnosis

The most common causes of late diagnosis include:

• Patient with vertebrogenic algic syndrome is treated by physiotherapists for several months, without the initial X-ray examination of spine. The X-ray performance costs CZK 200, while late diagnosis leading to the necessity of supportive orthopaedic treatment costs tens of thousands of crowns, another tens of thousands of crowns are spent on social security benefits during sickness leave.
• Anaemia is ascribed to old age and deprecated. The most common erroneous measure taken in anaemia in the Czech Republic is supplying iron, though its deficiency has not been proved by low level of ferritin and ferrum and thus the cause of iron deficiency has not been determined.
• Renal insufficiency is ascribed to diabetic nephropathy, without examining the immunoelectorphoresis in serum and in urine (Bence-Jones proteins).
• Patient with obvious signs of multiple myeloma is not refered to hematologist on time, is treated inadequately, or even not treated at all on the basis of infaust prognosis of the myeloma, without consulting a hematology specialist.

Multiple myeloma diagnosis is based on three key criteria – excess level of plasma cells in bone marrow, histology proof of myeloma and finding of osteolytic lesions and monoclonal paraprotein in blood or in urine.
The traditional Durie-Salmon division to stages I–III, based on hemoglobine level, level of paraprotein, bones affection and calcaemia, and subclassification A and B according to creatinine level (creatinine under or over 177 umolpl) is still in use. New international prognosis indicator called International Scoring System (ISS) is based on level of Beta 2-microglobulin and albumin: ISS 1 – albumin > 35 a B2M < 3.5, ISS 2 – albumin < 3.5 a B2M < 3.5, or B2M 3.5–5.5 without regard to albumin level, ISS 3 B2M > 5,5 without regard to albumin level.
Another significant factor determining the prognosis is patient’s age and his or her response to first line therapy. This is the reason for the focus on the administration of the most effective treatment in the initial stage that would, ideally, bring the patient to complete remission. Such treatment should be led by an experienced oncologist/hematologist. The standard initial therapy used for all the newly diagnosed patients in the Czech Republic combines alkylating agents (melphalan, cyclophosohamide) with corticosteroids and other chemotherapeutic agents, recently also with thalidomide and subsequent autologous peripheral stem cell transplant. Senior patients (over 65) are treated with combination of MP (melphalan prednisone), instead of autologous transplant. These days, new drugs administration significantly improve patients’ prognosis becoming standard treatment option in this group as well.
Another new drug showing outstanding treatment potential is bortezomib (Velcade), registered in the Czech Republic for relapse therapy. Like thalidomide, bortezomib has many side effects – namely development of thrombocytopenia, peripheral polyneuropathy or gastric difficulties. These undesirable side effects, however, can be relatively well controlled by dosage modificatons.