Multiple myeloma, the third most common blood cancer, is often discovered following multiple prediagnostic consultations, with delays in diagnosis resulting from the ubiquitous nature of presenting symptoms. delays result in high disease burden, greater end-organ damage, and emergency presentation, all of which are associated with poorer outcomes. improving the early diagnosis of myeloma remains an area of unmet clinical need. in this editorial, we describe the issues with the current diagnostic process, explore the potential impact of the covid-19 pandemic, and identify alternative strategies that may improve the early diagnosis of myeloma. diagnostic problem myeloma has one of the longest diagnostic intervals of all cancers. around half of myeloma patients have three or more pre- referral consultations and around one- third are diagnosed through emergency presentation. there are various reasons for this. it is a relatively rare cancer; an average gp will see one new case every 8-10 years. patients present with a range of non-specific symptoms, including back pain, bone pain, fatigue, and blood test abnormalities (hypercalcaemia, renal impairment, anaemia, and raised crp), which are all common in an ageing population and often attributable to concurrent conditions. early diagnosis of myeloma is crucial in limiting disease-related complications, such as lytic bone disease, pathological fractures, kidney injury, and severe infection, all of which may impact long-term quality of life, eligibility for routine or experimental therapy, treatment tolerance, response rates, and survival. impact of covid-19 and changes to general practice consultations the covid-19 pandemic resulted in a substantial decrease in myeloma referrals and diagnoses, in parallel with an increase in emergency presentations. reductions in overall urgent referrals for suspected cancer were mainly due to changes in patient attendance, rather than gp referral behaviour. consultation rates for specific symptoms for other cancers, including red-flag symptoms (such as breast lump and rectal bleeding), reduced during the first lockdown and returned to expected rates within months. however, consultation rates for non-specific symptoms common in myeloma patients (such as back pain, bone pain, and fatigue) remained below expected levels at the end of 2020. given the current workload pressures in general practice, patients with non-specific symptoms may prioritise other health concerns, or fail to present at all due to concerns about wasting doctors’ time. gps have adopted alternative approaches to triage and consulting, including electronic data capture to triage patients and alternatives to face-to-face consultations. gps may not prioritise non- specific symptoms, as e-consults will automatically ‘red flag’ some symptoms but not non-specific symptoms. we need to understand how this affects patients’ behaviour with non-specific cancer symptoms and presentation in general practice, especially for older patients and those with lower health literacy
