Cancer Association of South Africa (CANSA) Fact Sheet on Multiple Myeloma

Transcription

1 Cancer Assciatin f Suth Africa (CANSA) Fact Sheet n Multiple Myelma Intrductin Multiple myelma, als knwn as myelma, is a haematlgic cancer, r cancer f the bld. It is the secnd mst cmmn bld cancer, after nn- Hdgkin s lymphma and represents apprximately 1% f all cancers in white individuals and 2% f all cancers in black individuals. [Picture Credit: Bne Marrw] Multiple myelma develps in the bne marrw, the sft, spngy centre f mst bnes. Myelma typically ccurs in bne marrw with the mst activity, which is the marrw in the spine, pelvic bnes, ribs and area f the shulders and hips. Many bld cells are prduced in the bne marrw; myelma affects plasma cells, cells that prduce immungbulins (antibdies) that help fight infectin and disease. [Picture Credit: Malignant Myelma Cells] In multiple myelma, nrmal plasma cells transfrm int malignant myelma cells and prduce large quantities f an abnrmal immunglbulin called mnclnal (M) prtein. The malignant cells als crwd ut and inhibit the prductin f nrmal bld cells and antibdies in the bne marrw. In additin, grups f myelma cells cause ther cells in the bne Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved fr Distributin by Ms Elize Jubert, Acting CEO December 2014 Page 1

2 marrw t remve the slid part f the bne and cause sft spts in the bne. These sft spts, als called stelytic lesins, and ther signs f bne lss are cmmn, althugh they d nt ccur in all individuals with myelma. (Multiple Myelma Research Fundatin). Ostelytic Lesins Ostelytic lesins, als called steclastic lesins r lytic lesins (fr shrt), are characteristic areas f damage caused by myelma. When myelma invades bne tissue, it causes weak areas t frm. In additin, the myelma cells release chemicals that als lead t bne breakdwn. The result is lesins with a specific punched-ut appearance that may ccur in any bne in the bdy, but are mst ften nted in the spine, skull, pelvis and ribs (Abut.Cm). [Picture Credit: Ostelytic Lesins] Incidence f Multiple Myelma in Suth Africa Accrding t the Natinal Cancer Registry () the fllwing number f leukaemia cases were histlgically diagnsed in Suth Africa during : Grup - Males N f Cases Lifetime Risk All males 177 1:736 Asian males 5 1:986 Black males 99 1:1 003 Clured males 14 1:515 White males 58 1:445 Grup - Females N f Cases Lifetime Risk All females 121 1:1 514 Asian females - - Black females 77 1:1 730 Clured females 13 1:1 410 White females 31 1:923 The frequency f histlgically diagnsed cases f leukaemia in Suth Africa fr were as fllws (Natinal Cancer Registry, ): Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved fr Distributin by Ms Elize Jubert, Acting CEO December 2014 Page 2

3 Grup - Males All males Asian males Black males Clured males White males Grup - Females All females Asian females Black females Clured females White females N.B. In the event that the ttals in any f the abve tables d nt tally, this may be the result f uncertainties as t the age, race r sex f the individual. The ttals fr all males and all females, hwever, always reflect the crrect ttals. Symptms f Multiple Myelma Myelma may nt cause any symptms in the early stages f the disease. Occasinally, it is diagnsed fllwing a rutine bld test befre any symptms develp. When symptms d happen, they are mstly caused by a build-up f abnrmal plasma cells in the bne marrw, and by the presence f the para-prtein in the bld. Bne pain - The mst cmmn symptm f myelma is bne pain. Abut 70% f peple (7 in 10) cmplain f lwer back pain, r pain in their ribs. The pain happens because t many abnrmal plasma cells are crwding ut the bne marrw, which can damage the bne. Other bnes may be affected t, such as the skull r pelvis Other symptms include: These may include: tiredness and fatigue due t a lack f red bld cells (anaemia) kidney prblems, which are caused by the para-prteins prduced by the myelma cells. They can als cause tiredness and anaemia repeated infectins, particularly chest infectins, due t a shrtage f nrmal antibdies lss f appetite, feeling sick, cnstipatin, depressin and drwsiness, which are caused by t much calcium in the bld (hypercalcaemia) unexplained bruising and abnrmal bleeding, fr example nsebleeds r bleeding gums, due t a reduced number f platelets in the bld weight lss If a persn has any f these symptms, it is imprtant t see a dctr as sn as pssible. Many f these symptms can ccur in ther cnditins - mst peple with these symptms will nt have multiple myelma. (MacMillan Cancer Supprt). Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved fr Distributin by Ms Elize Jubert, Acting CEO December 2014 Page 3

4 Causes and Risk Factrs fr Multiple Myelma N cause fr myelma has s far been identified. Sme research has suggested pssible assciatins with a decline in the immune system, specific ccupatins, expsure t certain chemicals, and expsure t radiatin. The likelihd f multiple myelma is higher than average amng peple in agricultural ccupatins, petrleum wrkers, wrkers in leather industries and csmetlgists. Expsure t herbicides, insecticides, petrleum prducts, heavy metals, plastics, and varius dusts including asbests als appear t be risk factrs fr the disease. Hwever, nne f these assciatins is strng, and in mst cases, multiple myelma develps in individuals wh have n knwn risk factrs. Genetic factrs may als be invlved in the develpment f multiple myelma. Learn mre abut genetic abnrmalities in multiple myelma. Researchers believe that multiple myelma is mst likely the result f several factrs acting tgether. The mst significant risk factr fr multiple myelma is age, as 96% f cases are diagnsed in peple lder than 45 years, and mre than 63% are diagnsed in peple lder than 65 years. Thus, it is thught that susceptibility t myelma may increase with the aging prcess. It is uncmmn fr myelma t develp in mre than ne member f a family. This means that if yu have myelma, yu prbably d nt need t wrry abut the disease develping in anther family member. There is a slightly increased risk f myelma ccurring in children r siblings f individuals wh have the disease. (Multiple Myelma Research Fundtin). Diagnsis f Multiple Myelma The fllwing tests can be dne t diagnse multiple myelma A bld test called serum prtein electrphresis separates the bld prteins and can detect the presence f mnclnal prteins (M prteins) referred t as an "M spike" in the bld. Parts f M prteins may als be detected in a test f ne s urine. When M prteins are fund in urine, it is referred t as Bence Jnes prteins. Mnclnal prteins may indicate multiple myelma, but als can indicate ther cnditins. If the dctr discvers M prteins, additinal bld tests may be required t measure bld cell cunts and levels f calcium, uric acid and creatinine. The dctr may als cnduct ther bld tests t check fr beta-2-micrglbulin anther prtein prduced by myelma cells r t measure the percent f plasma cells in the bne marrw. Other tests may include: Imaging - X-rays f the skeletn can shw whether the bnes have any thinned-ut areas (stelytic lesins), cmmn in multiple myelma. If a clser view f the bnes is necessary, the dctr may use magnetic resnance imaging (MRI), cmputerised tmgraphy (CT) scanning r psitrn emissin tmgraphy (PET) scanning. Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved fr Distributin by Ms Elize Jubert, Acting CEO December 2014 Page 4

5 Bne marrw examinatin - the dctr may als cnduct a bne marrw examinatin (bipsy) by using a needle t remve a small sample f bne marrw tissue. The sample is then examined under a micrscpe t check fr myelma cells. A prtin f the sample is als tested fr chrmsme abnrmalities using tests such as flurescence in situ hybridisatin (FISH). [Picture Credit: Bne Marrw Bipsy] Tests are als dne t measure the rate at which the plasma cells are dividing. (May Clinic). Staging f Multiple Myelma Staging is the prcess f finding ut hw much the cancer has advanced. It is imprtant fr treatment ptins and prgnsis. Prgnsis is a predictin f the curse f disease the utlk fr survival. Knwing all ne can abut staging lets ne take a mre active rle in making infrmed decisins abut ne s treatment. Multiple myelma may be staged using the Durie-Salmn system. Althugh sme dctrs use this system, its value is becming limited because f newer diagnstic methds. Recently, a new staging system called the Internatinal Staging System fr Multiple Myelma has been develped. It relies mainly n levels f albumin and beta-2-micrglbulin in the bld. Other factrs that may be imprtant are kidney functin, platelet cunt and the patient's age. The Durie-Salmn Staging System fr Multiple Myelma This system is based n 4 factrs: the amunt f abnrmal mnclnal immunglbulin in the bld r urine: Large amunts f mnclnal immunglbulin indicate that many malignant plasma cells are present and are prducing that abnrmal prtein the amunt f calcium in the bld: High bld calcium levels can be related t advanced bne damage. Because bne nrmally cntains lts f calcium, bne destructin releases calcium int the bld the severity f bne damage based n x-rays: Multiple areas f bne damage seen n x-rays indicate an advanced stage f multiple myelma the amunt f hemglbin in the bld: Hemglbin carries xygen in red bld cells. Lw hemglbin levels mean yu are anemic and can indicate that the myelma cells ccupy much f the bne marrw and that nt enugh space is left fr the nrmal marrw cells t make enugh red bld cells This system uses these factrs t divide myelma int 3 stages. Stage I indicates the smallest amunt f tumr, and stage III indicates the largest amunt f tumr: Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved fr Distributin by Ms Elize Jubert, Acting CEO December 2014 Page 5

6 Stage I - a relatively small number f myelma cells are fund. All f the fllwing features must be present: haemglbin level is nly slightly belw nrmal (still abve 10 g/dl) bne X-rays appear nrmal r shw nly 1 area f bne damage calcium levels in the bld are nrmal (less than 12 mg/dl) nly a relatively small amunt f mnclnal immunglbulin is in bld r urine Stage II - a mderate number f myelma cells are present. Features are between stage I and stage III Stage III - a large number f myelma cells are fund. One r mre f the fllwing features must be present: lw haemglbin level (belw 8.5 g/dl) high bld calcium level (abve 12 mg/dl) 3 r mre areas f bne destryed by the cancer large amunt f mnclnal immunglbulin in bld r urine The Internatinal Staging System This system divides myelma int 3 stages based nly n the serum beta-2 micrglbulin and serum albumin levels. Stage I - serum beta-2 micrglbulin is less than 3.5 (mg/l) and the albumin level is abve 3.5 (g/l) Stage II - neither stage I r III, meaning that either: the beta-2 micrglbulin level is between 3.5 and 5.5 (with any albumin level), OR the albumin is belw 3.5 while the beta-2 micrglbulin is less than 3.5 Stage III - serum beta-2 micrglbulin is greater than 5.5. (American Cancer Sciety). Treatment f Multiple Myelma Because currently there is n knwn cure fr multiple myelma, understanding the standard treatments - and the treatment ptins - is critical in attempting t prlng survival and maintain the patient's verall functinal ability and quality f life. Aspects f imprtance in the treatment f multiple myelma include: Which patients with multiple myelma are candidates fr an apprach knwn as watchful waiting, where the prgress f the disease is mnitred carefully but n specific treatment is required The varius phases in the treatment f multiple myelma fr patients whse disease has prgressed t the pint where treatment becmes necessary. These treatment phases are gruped int the fllwing categries: initial r inductin chemtherapy cnslidatin therapy maintenance therapy salvage therapy The rle f stem cell transplantatin in the management f patients with multiple myelma, including the risks and benefits f this prcedure Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved fr Distributin by Ms Elize Jubert, Acting CEO December 2014 Page 6

7 The treatment ptins available t patients with multiple myelma wh experience a relapse r recurrence f the disease after initially having gne int remissin The rle f plasmapharesis - the direct remval f abnrmal antibdy prteins frm the bldstream - in the management f patients with multiple myelma A detailed verview f the risk f infectins in peple with multiple myelma, including practical recmmendatins fr reducing the risks f develping ptentially life-threatening bacterial, viral, and fungal infectins The treatment ptins that are available fr the management f patients with multiple myelma wh develp myelma bne disease - areas f bne destructin caused by multiple myelma that significantly increase the risk f develping pathlgic fractures The prgnsis (utlk) fr peple with multiple myelma and imprtant prgnstic factrs that have a significant impact in predicting the verall chances f recvery and survival The rle f cmplementary therapies in the management f peple with multiple myelma Quality f life issues such as sleep disrders, fatigue, weight lss, and psychlgical stress that ften cnfrnt peple with multiple myelma and tips fr hw t minimize their impact and better cpe with these imprtant issues (Medifcus). If ne has multiple myelma and is nt experiencing any symptms, he/she may nt need treatment. Hwever, the dctr will regularly mnitr the patient s cnditin fr signs the disease is prgressing. If it is, the patient may need treatment. If ne is experiencing symptms, treatment can help relieve pain, cntrl cmplicatins f the disease, stabilise the cnditin and slw the prgress f the disease. Standard treatments fr multiple myelma Thugh there's n cure fr multiple myelma, with gd treatment results ne can usually return t near-nrmal activity. Standard treatment ptins include: Brtezmib (Velcade). Brtezmib was the first apprved drug in a new class f medicatins called prteasme inhibitrs. It is administered intravenusly. It causes cancer cells t die by blcking the actin f prteasmes. It is apprved fr peple with newly diagnsed and previusly treated myelma. Thalidmide (Thalmid). Thalidmide, a drug riginally used as a sedative and t treat mrning sickness during pregnancy in the 1950s, was remved frm the market after it was fund t cause severe birth defects. Hwever, the drug received apprval frm the Fd and Drug Administratin (FDA) again in 1998, first as a treatment fr skin lesins caused by leprsy. Tday thalidmide is FDA apprved fr the treatment f newly diagnsed multiple myelma. This drug is given rally. Lenalidmide (Revlimid). Lenalidmide is chemically similar t thalidmide, but because it appears t be mre ptent and cause fewer side effects, it is currently used mre ften than thalidmide. Lenalidmide is given rally. It is apprved fr peple with previusly treated myelma, but is als ften used in peple with newly diagnsed disease. Chemtherapy. Chemtherapy invlves using medicines taken rally as a pill r given thrugh an intravenus (IV) injectin t kill myelma cells. Chemtherapy is ften given in Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved fr Distributin by Ms Elize Jubert, Acting CEO December 2014 Page 7

8 cycles ver a perid f mnths, fllwed by a rest perid. Often chemtherapy is discntinued during what is called a plateau phase r remissin, during which yur M prtein level remains stable. Yu may need chemtherapy again if yur M prtein level begins t rise. Cmmn chemtherapy drugs used t treat myelma are melphalan (Alkeran), cyclphsphamide (Cytxan), vincristine, dxrubicin (Adriamycin) and lipsmal dxrubicin (Dxil). Crticsterids. Crticsterids, such as prednisne and dexamethasne, have been used fr decades t treat multiple myelma. They are typically given in pill frm. Stem cell transplantatin. This treatment invlves using high-dse chemtherapy usually high dses f melphalan alng with transfusin f previusly cllected immature bld cells (stem cells) t replace diseased r damaged marrw. The stem cells can cme frm yu r frm a dnr, and they may be frm either bld r bne marrw. Radiatin therapy. This treatment uses high-energy penetrating waves t damage myelma cells and stp their grwth. Radiatin therapy may be used t quickly shrink myelma cells in a specific area fr instance, when a cllectin f abnrmal plasma cells frm a tumr (plasmacytma) that's causing pain r destrying a bne. Initial therapy fr multiple myelma The initial chemtherapy used t treat multiple myelma depends n whether the patient is cnsidered a candidate fr stem cell transplantatin and his/her individual risk prfile. Factrs such as the risk f the disease prgressing, the age and general health play a part in determining whether stem cell transplantatin may be right. If cnsidered a candidate fr stem cell transplantatin, the initial therapy will likely exclude melphalan because this drug can have a txic effect n stem cells, making it impssible t cllect enugh f them. The first treatment will typically be lenalidmide r brtezmib cmbined with lw-dse dexamethasne. The stem cells will likely be cllected after the patient has undergne three t fur mnths f treatment with these initial agents. The patient may underg the stem cell transplant sn after the cells are cllected r the transplant may be delayed until after a relapse, if it ccurs. The age and persnal preference f the patient are imprtant factrs in determining when t d the transplant. After the stem cell transplantatin, the patient will likely start a new curse f treatment with a drug cmbinatin that includes brtezmib and melphalan. If nt cnsidered a candidate fr stem cell transplantatin, the initial therapy is likely t be a cmbinatin f melphalan, prednisne and thalidmide ften called MPT r melphalan, prednisne and brtezmib (Velcade) ften called MPV. If the side effects are intlerable, melphalan plus prednisne (MP) r lenalidmide plus lw-dse dexamethasne are additinal ptins. This type f therapy is typically given fr abut 12 t 18 mnths. Treatments fr relapsed r treatment-resistant multiple myelma Mst peple wh are treated fr multiple myelma eventually experience a relapse f the disease. In sme cases, nne f the currently available, first line therapies slw the cancer cells frm multiplying. If the patient experiencea a relapse f multiple myelma, the dctr may recmmend repeating anther curse f the treatment that initially helped. Anther Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved fr Distributin by Ms Elize Jubert, Acting CEO December 2014 Page 8

9 ptin is trying ne r mre f the ther treatments typically used as first line therapy, either alne r in cmbinatin. Research n a number f new treatment ptins is nging, and these drugs ffer imprtant ptins fr thse with multiple myelma. Talk t a dctr abut what clinical trials may be available t yu. (May Clinic). Treating Cmplicatins f Multiple Myelma Because multiple myelma can cause a number f cmplicatins, yu may als need treatment fr thse specific cnditins. Fr example: Back pain - taking pain medicatin r wearing a back brace can help relieve the back pain the patient might experience with multiple myelma Kidney cmplicatins - peple with severe kidney damage may need dialysis Infectins - antibitics may be necessary t help treat infectins r t help reduce the risk f them Bne lss the patient may be given medicatins called bisphsphnates, such as pamidrnate (Aredia) r zledrnic acid (Zmeta), which bind t the surface f the bnes and help prevent bne lss. Treatment with these drugs is assciated with the risk f harm t the jawbne. If the patient is taking these medicatins, avid dental prcedures withut cnsulting a dctr first Anaemia - if a patient has persistent anaemia, the dctr may prescribe erythrpietin injectins. Erythrpietin is a naturally ccurring hrmne made in the kidneys that stimulates the prductin f red bld cells. Research suggests that the use f erythrpietin may increase the risk f bld clts in sme peple with myelma (May Clinic). Treating Multiple Myelma with a Measles Virus During May 2014 the wrld was awash with the dramatic news that researchers in the May Clinic, United States f America, had apparently cured a patient with multiple myelma using a measles virus. Since the turn f the nineteenth century the existence f viruses that culd pssibly destry tumurs was first recgnised. Early case reprts f making use f nclytic viruses (a virus that preferentially infects and kills cancer cells) frm that time reprted the shrinking f sme cancer tumurs during naturally acquired virus infectins. This prvided the basis fr clinical trials where bdy fluids cntaining human r animal viruses were used t transmit infectins t cancer patients. In mst cases the immune f the hst destryed the viruses befre they culd have any effect. In patients whse immune system was cmprmised, the viral infectin persisted and sme f the tumurs regressed. With the advent f rdent experimentatin and new methds fr virus prpagatin, there were numerus attempts thrugh the 1950s and 1960s t frce the evlutin f viruses with greater tumur specificity. Success was limited and many researchers abandned the field. Technlgy emplying Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved fr Distributin by Ms Elize Jubert, Acting CEO December 2014 Page 9

10 reverse genetic mdificatin later brught abut a renewal f interest in making use f viruses that allwed the creatin f mre ptent, tumur-specific types f viruses that infects and breaks dwn cancer cells but nt nrmal cells (Kelly & Russell, 2007). It is imprtant t knw that the virus that used in the May Clinic t treat a case f multiple myelma, was nt a standard measles virus but a measles virus that was specifically engineered (mdified) fr the purpse f breaking dwn the myelma (cancer cells) in tw specific patients. Engineered measles viruses were used in this instance because neither f the tw patients had previusly been immunised against measles and neither f them had any resistance t measles because they did nt have measles during their lifetime. This means that they were bth measles-sernegative. Bth patients were diagnsed with multiple myelma. They had bth been unsuccessfully treated by means f cnventinal therapy fr between 7 and 9 years respectively and had bth received stem cell transplants. Bth patients als had multiple recurrences f their disease. They were bth given a large single dse (apprximately 100 billin units enugh t vaccinate 10 millin peple had it been a regular vaccine virus) f the specifically engineered virus (MV-NIS virus). Bth patients became very ill and regrettably ne patient died. The secnd patient (Ms Stacy Erhltz) received intensive care and supprt and survived the treatment and was eventually declared t be in remissin. [Picture Credit: Ms Stacy Erhltz] The best apprach t this spectacular news is cautius ptimism. There is still much research t be dne. Remarkably little is still knwn abut the best way t deliver nclytic viruses intravenusly. The speed and duratin f infusin, the quantity f virus, and the number f dses t be administered are als still prly understd at this time. Hwever, nclytic viruses ffer a prmising new mdality fr the targeted infectin and destructin f disseminated cancer (Bell, 2014; Russell, et al., 2014). Clinical Trials Clinical trials are research studies that invlve peple. They are the final step in a lng prcess that begins with research in a lab. Mst treatments used tday are the results f past clinical trials. Cancer clinical trials are designed t test new ways t: Treat cancer Find and diagnse cancer Prevent cancer Manage symptms f cancer r side effects frm its treatment Every trial has a persn in charge, usually a dctr, wh is called the principal investigatr. The principal investigatr prepares a plan fr the trial, called a prtcl. The prtcl explains what will be dne during the trial. It als cntains infrmatin that helps the dctr decide if this treatment is right fr a particular patient. Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved fr Distributin by Ms Elize Jubert, Acting CEO December 2014 Page 10

11 The prtcl includes infrmatin abut: The reasn fr ding the trial Wh can jin the trial (called eligibility requirements ) Hw many peple are needed fr the trial Any drugs that will be given, hw they will be given, the dse, and hw ften What medical tests will be dne and hw ften What types f infrmatin will be cllected abut the peple taking part Fr sme patients, taking part in a clinical trial may be the best treatment chice. Clinical trials are part f the cancer research prcess. Many f tday's standard treatments fr cancer are based n earlier clinical trials. Patients wh take part in a clinical trial may receive the standard treatment r be amng the first t receive a new treatment. Patients wh take part in clinical trials als help imprve the way cancer will be treated in the future. Even when clinical trials d nt lead t effective new treatments, they ften answer imprtant questins and help mve research frward. Patients can enter clinical trials befre, during, r after starting their cancer treatment. Sme clinical trials nly include patients wh have nt yet received treatment. Other trials test treatments fr patients whse cancer has nt gtten better. There are als clinical trials that test new ways t stp cancer frm recurring (cming back) r reduce the side effects f cancer treatment. (Natinal Cancer Institute). Medical Disclaimer This Fact Sheet is intended t prvide general infrmatin nly and, as such, shuld nt be cnsidered as a substitute fr advice, medically r therwise, cvering any specific situatin. Users shuld seek apprpriate advice befre taking r refraining frm taking any actin in reliance n any infrmatin cntained in this Fact Sheet. S far as permissible by law, the Cancer Assciatin f Suth Africa (CANSA) des nt accept any liability t any persn (r his/her dependants/estate/heirs) relating t the use f any infrmatin cntained in this Fact Sheet. Whilst the Cancer Assciatin f Suth Africa (CANSA) has taken every precautin in cmpiling this Fact Sheet, neither it, nr any cntributr(s) t this Fact Sheet can be held respnsible fr any actin (r the lack theref) taken by any persn r rganisatin wherever they shall be based, as a result, direct r therwise, f infrmatin cntained in, r accessed thrugh, this Fact Sheet. Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved fr Distributin by Ms Elize Jubert, Acting CEO December 2014 Page 11

12 Surces and References Abut.Cm American Cancer Sciety Bell, J.C Taming measles virus t create an effective cancer therapeutic. May Clinical Prceedings, XXX: Bne Marrw UeKjGc- IhQe844CQAQ&ved=0CAcQ_AUAQ&biw=1366&bih=614#facrc=_&imgdii=_&imgrc=P67x5 vdfaklxjm%3a%3bfguopzugsy_l5m%3bhttp%253a%252f%252fsicklecellbdyplitics. files.wrdpress.cm%252f2011%252f04%252fbnemarrw2.jpg%3bhttp%253a%252f%2 52Fsicklecellbdyplitics.wrdpress.cm%252Ftreatment-and-research%252Fprimarymedical-treatments%252Ftransplantatin%252Fwhat-is-bnemarrw%252F%3B1681%3B1557 Bne Marrw Bipsy i=lj7uydetcwhqfylycwdg&sqi=2&ved=0cacq_auaq&biw=1366&bih=614#facrc=_&imgdii=_&i mgrc=uto8gxevc897cm%3a%3bbh4vfsdoabq0mm%3bhttp%253a%252f%252fwww. medindia.net%252fpatients%252fpatientinf%252fimages%252fbne-marrwbipsy.jpg%3bhttp%253a%252f%252fwww.medindia.net%252fpatients%252fpatientinf %252Fbne-marrw-aspiratin-and-bipsy.htm%3B390%3B260 Cancer Research UK Kelly, E. & Russell, S.J Histry f nclytic viruses: genesis t genetic engineering. Mlecular Therapy, 15(4): MacMillan Cancer Supprt Symptms.aspx Malignant Myelma Cells q77udcko8tk0ax23gqba&ved=0cacq_auaq&biw=1366&bih=614#facrc=_&imgdii=_ &imgrc=a0un5bnuko9urm%3a%3bvrltaiaban27fm%3bhttp%253a%252f%252fannals. rg%252fdata%252fjurnals%252faim%252f19777%252f11ff1.jpeg%3bhttp%253a%2 52F%252Fannals.rg%252Farticle.aspx%253Farticleid%253D706496%3B1280%3B822 May Clinic Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved fr Distributin by Ms Elize Jubert, Acting CEO December 2014 Page 12

13 Medifcus yelma Ms Stacy Erhltz 7eaU9X5HKv7Aba5YH4Bg&ved=0CAYQ_AUAQ&biw=1517&bih=714&dpr=0.9#facrc=_&imgdii=_&imgr c=4df2t2ukhj37lm%253a%3bgxm8ecwvmz7pgm%3bhttp%253a%252f%252fi2.cdn.tur ner.cm%252fcnn%252fdam%252fassets%252f newsrm-intv-stacyerhltz-cancer-survivr strytp.jpg%3bhttp%253a%252f%252fwww.cnn.cm%252f2014%252f05%252f15%252fhe alth%252fmeasles-cancer-remissin%252f%3b640%3b360 Multiple Myelma Research Fundatin Natinal Cancer Institute Ostelytic Lesins q77udcko8tk0ax23gqba&ved=0cacq_auaq&biw=1366&bih=614#facrc=_&imgdii=_ &imgrc=jkc6xvyle64ypm%3a%3bvnl2lwxrvxnrm%3bhttp%253a%252f%252fapi.ning. cm%252ffiles%252fzpssdf8q4nccfd*o*qrhizceiyquewdmfbodzf8iry5yiu4i574as yd1wsxfcqgt0i7gvqlqagdeirl477nwpp-1- i7grq%252fmultiplemyelma.png%3bhttp%253a%252f%252fwww.radrunds.cm%252f pht%252fmultiple-myelma-2%3b1357%3b1010 Russell, S.J., Federspeil, M.J., Peng, K.W., Tng, C., Dingli, D., Mrine, W.G., Lwe, V., O Cnnt, M.K., Kyle, R.A., Leung, N., Buadi, F.K., Rajkumar, S.V., Gertz, M.A., Lacy, M.Q. & Dispenzieri, A Remissin f disseminated cancer after systemic nclytic virtherapy. May Clinic Prceedings, XXX: Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved fr Distributin by Ms Elize Jubert, Acting CEO December 2014 Page 13