Advancements in the diagnosis and staging of multiple myeloma continue to shape treatment decisions and improve outcomes.
There are multiple factors that doctors take into consideration when diagnosing and staging multiple myeloma, leading to better treatment for the disease, explained Dr. Nikhil C. Munshi.
Munshi, director of basic and correlative science at the Jerome Lipper Multiple Myeloma Center at Dana-Farber Cancer Institute, recently discussed diagnosis and risk assessment in myeloma at CURE®’s Multiple Myeloma Educated Patient® Summit.
To diagnose myeloma, doctors traditionally start with a blood test. Then, they usually conduct a bone marrow biopsy to determine how many myeloma cells are in the patient’s bone marrow. Finally, patients may undergo an X-ray to see if there are any holes in the bones, which would indicate progressive disease.
“This is the standard workup that we have been doing for the last 15 or more years,” Munshi said. “But now, (clinicians) are doing many more things.”
More recently, serum-free light chain (SFLC) testing has become standard. SLCL tests for immunoglobulins, which are partially made up of light chains, in the blood. When there are more light chains than heavy chain, the immunoglobulin cannot bind to them, making them free in the blood. A high level of free light chains indicates that there may be an issue.
The blood tests that are used in myeloma diagnosis have evolved too. Clinicians will perform protein electrophoresis, where they are looking for monoclonal spike – commonly referred to as “m spike.” In doing so, they are able to test the amount of myeloma that is in the blood.
“A higher level means that there is more myeloma,” Munshi explained. “When the level goes down, we know that the myeloma is being controlled.”
This test can tell if myeloma treatment is working or not. Now that there is a simple blood test, patients may not need to undergo bone marrow biopsies as much.
Once myeloma is diagnosed, clinicians look at the prognosis of the disease, as well as the molecular makeup to determine which treatment would be best.
When a patient has symptomatic myeloma – which can include affected kidney function and/or bone lesions – they should be treated.
X-rays, PET and CT scans are also used to determine to what extent the myeloma has affected the patient’s bones and surrounding regions, such as the liver.
“In the old days, when bone marrow was involved to 70, 80 or even 90%, we wouldn’t start treatment,” Munshi said. “Now this new criteria tells us that if it is more than 60%, we should begin to think about treating this patient.”
When it comes to prognosis, doctors analyze proteins such as albumin and beta 2 macroglobulin, as well as results from a fluorescence in situ hybridization (FISH) genetic test.
“In looking at the genetic makeup of the multiple myeloma, we can establish the long-term plan. We could say, ‘since your myeloma is on the more aggressive side, we’ll need to do treatment for a longer period of time,” Munshi said.
However, Munshi explained that patients should not get too caught up in the stage of myeloma that they are given. A late-stage (stage 3 or 4) diagnosis might not be as deadly in myeloma as it is for other cancers.
“The reason is that even those who are stage 3 do quite well with new treatment and with the new drugs we have,” Munshi said, explaining that a stage 3 patient might receive a multi-drug maintenance regimen instead of a single-drug therapy.
“What we are beginning to do is incorporate more knowledge that we are gathering over time, looking at mutations and other things to make this next generation of staging a system that is comprehensive. And we need to keep that in mind,” Munshi said.
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