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Understanding Myeloma Testing and Monitoring | An Overview

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Understanding Myeloma Testing and Monitoring | An Overview from Patient Empowerment Network on Vimeo.

What should patients know about myeloma treatment and testing? Dr. Sikander Ailawadhi shares an overview of myeloma testing and discusses the importance of getting key questions answered by your healthcare team. 

Dr. Sikander Ailawadhi is a hematologist and oncologist specializing in myeloma at Mayo Clinic in Jacksonville, Florida. Learn more about Dr. Ailawadhi.

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Available Myeloma Treatment Options for Patients | An Overview

Transcript:

Katherine:

What sort of tests should be done following a myeloma diagnosis?   

Dr. Ailawadhi:

Generally, when myeloma is suspected, we need to know what the basic blood counts are, something that is called a CBC, complete blood count. We’re looking for anemia, low white blood cells, low clotting cells, or platelets. We want to do serum chemistries or blood chemistries, looking for kidney function, liver function, electrolytes, calcium, et cetera.  

Then, we want to do some kind of an imaging of the body. Generally, routine X-rays are no longer done, and the most preferred is a PET-CT scan, a PET scan. We do PET-MRIs frequently. So, there are different tests available, but you want a good test to know what’s the state of bones and presence of any lesions or tumors. And then, the important question comes is doing a bone marrow biopsy.   

The reason for doing a bone marrow biopsy, and even if somebody has had a biopsy done from a compression fracture, et cetera, that diagnosed myeloma, a bone marrow biopsy still should be done. It gives us a lot of pieces of information.  

It tells us what is the percentage of plasma cells in the bone marrow. So, what is the disease burden we are starting with? Secondly, that bone marrow biopsy specimen can be sent for what is called a FISH testing, which is fluorescent in situ hybridization.  

It is basically looking for any mutations in the cancer cells. Based on those mutations, myeloma can be classified into standard or high-risk myeloma. And sometimes our treatment choices are differed based on whether somebody is standard or high-risk. So, blood work, basic counts – and I skipped over one of the things. Right after chemistries, I wanted to add also are myeloma markers.  

There are typically three lab tests of myeloma markers. One is called protein electrophoresis. It can be run in blood and urine. Ideally, it should be run in both. One is immunoglobulin levels, which gives us the level of IgG, IgA, IgM, et cetera. And the third one is serum-free light chains, which is kappa and lambda light chains. Neither one – none of these tests eliminates the needs for the other.

So, everybody, in the beginning, should have complete blood count, blood chemistries, SPEP or serum protein electrophoresis, urine electrophoresis, immunoglobulins, light chains, imaging, and then a bone marrow. This completes the workup. Then, based on that, the treatment can be determined.  

 Katherine:

Well, you mentioned lab work. How often should tests and blood work be done?   

Dr. Ailawadhi:

Good question. Very, very important question because we see very frequently that the patients come in, they’re getting treatment somewhere, and every single time the patient steps foot in the door of that institution or wherever they’re going, they got a blood draw. That’s how they start their day. It’s needed more frequently in the beginning but needed less frequently later on.

Generally, the myeloma markers, those protein electrophoresis, immunoglobulins, light chains, they are frequently done just about every month. Generally, in myeloma, one month, three to four weeks is one cycle. So, at the beginning of every cycle, you want to know how good your response was. So, the myeloma markers once a month.  

The blood counts and chemistries in the first month, first one to two months, they can be done every other week or so just to make sure counts are fine, no need for transfusions, kidney/liver is okay, et cetera. But after the first couple of months, when the body is used to the drugs when the patient is settled with the treatment, frankly, once-a-month labs are good enough. We don’t really need labs on every single treatment visit. Because the other thing that happens is some of these drugs can lower the blood counts normally during treatment, but they have a rest period at the end of the cycle when the counts recover.   

So, if somebody does labs in the middle of the cycle when the counts are expected to be down but not an issue, treatments are stopped, and growth factors are given. And this is done, but that is not really necessary. So, first couple of one to two cycles, maybe every other week to make sure counts are okay. Myeloma markers monthly, but after the first couple of months when things are settled, once a month should be sufficient. 

Katherine:

Okay. What questions should patients be asking about their test results?    

Dr. Ailawadhi:

Yeah. Very, very, very important. In fact, whenever I’m speaking in a patient caregiver symposium or anything, I spend a lot of time on these test results because frankly, a lot of times it sounds like jargon and the people talk about, “Oh, my ratio is going up,” or the doctor is saying, “Hey, your immunoglobulins are normal. You’re in remission.” But so, I think the patients need to understand and ask from their doctors, “What is my marker of the disease that you will be following?” And I’ll tell you that immunoglobulins, that IgG or IgA level, is nearly never the marker. It’s either M spike or light chains, generally one of those.  

So, the patients need to understand what is their marker. They also need to know what did their bone marrow show. What was the percentage and what was the FISH result or cytogenetic result? I think other than the tests, I will also add the patients need to ask their doctor a lot of these questions that you’re asking me. How frequently are the labs going to be done? Why is it important?  Why was a certain treatment selected? What is the expected outcome? What are the chances that I can go into remission? How long does the intense treatment stay?  

When does it go to some kind of a maintenance? Et cetera, et cetera. Basically, you want to understand everything about the disease and its treatment. It is overwhelming. This is a lot of information. A lot of times the patients may say, “Well, I got a diagnosis. I got a treatment started. I just need to move on.”  That’s right. But once you spend all that time initially understanding your diagnosis and the treatment and the disease, it’ll make the rest of the journey much, much easier.  

Is There a Link Between Myeloma and Dental Health?

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Is There a Link Between Myeloma and Dental Health? from Patient Empowerment Network on Vimeo.

Dr. Sikander Ailawadhi from Mayo Clinic explains that while multiple myeloma doesn’t commonly cause dental issues, there can be indirect connections via bone problems.

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Transcript:

Lisa Hatfield:

Another question from a patient since my diagnosis and bone marrow transplant, my teeth have been deteriorating, is there a connection between dental health and myeloma?

Dr. Sikander Ailawadhi:

Very important question because although this is not a very common finding, it is something that really affects quality of life, so myeloma itself does not always or frequently caused teeth problems or dentition problems, which you can imagine teeth are bones. Myeloma affects bones, Myeloma affects calcium deposition in bone so teeth can get damaged in two or three different ways in myeloma patients, first, if myeloma involves the job or you can imagine that the teeth in that particular area could become loose or they could become a little off because the structure is getting affected.

Sometimes if my novels present on the job, for example, and radiation is given, but that bone becomes weaker, so teeth can become weaker, another way myeloma and dental health can be connected is because we use certain bone-strengthening agents for myeloma. These drugs are called either bisphosphonates, for example, or zoledronic acid (Zometa) or pamidronate acid (Aredia), patients may know as Zometa or Aredia, or there’s a second category called RANK ligand inhibitors, one of the drugs there is denosumab or Xgeva, these are all drugs that are given for bone-strengthening for myeloma. Patients are recommended to take calcium and vitamin D, but a rare but definitive side effect that is known to happen or can happen with these drugs is what’s called osteonecrosis of the jaw, where basically the jaw bone is becoming necrosed or less viable.

And you can imagine if the jaw is less viable, the teeth that go into the jaw in that spot, they’ll become loose and hurt, painful…it’s not a good condition to have it very…it affects quality of life significantly. So while it is rare, this osteonecrosis of the jaw can occur maybe less than 10 percent of the cases, but it is a significant morbidity causing issue.

What I recommend to patients is that one, if that is happening, first of all, we’re not…we typically don’t continue that drug that is causing it, like a bisphosphonate or RANK ligand inhibitor. Secondly, the patient needs to see a good oral maxillofacial surgeon or a good dentist, preferably someone who has knowledge and experience in handling outreaches of the job. So different ways in which melodic treatment can affect the job, there is not a direct correlation, but in about 10 to 15 percent of cases, there may be care or death-related implications and monuments either from the disease or its treatment like radiation or bone-strengthening drugs. 

Bone-Building Therapies Recommended for Myeloma Patients

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Bone-Building Therapies Recommended for Myeloma Patients from Patient Empowerment Network on Vimeo.

What can multiple myeloma patients do for bone-building therapies? Dr. Sikander Ailawadhi from the Mayo Clinic discusses bone-strengthening drugs and some physical activities to help with bone care.

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Transcript:

Lisa Hatfield: 

So if a patient cannot take bisphosphates doesn’t explain the reason why, are there other bone-building therapies that are recommended to protect them?

Dr. Sikander Ailawadhi: 

Sure, so I would say that while we talk about these drugs like bisphosphonates, RANK ligand inhibitors, there are some other drugs that can be used to strengthen the bones, because you can imagine these molesting agents are used in a lot of different cancer, breast cancer, prostate cancer, etcetera. So this family of drugs can be used, there are some that are used less frequently, but can be used instead of bisphosphonates and denosumab (Prolia), but I would bring the patients back to even more basic stuff, calcium, vitamin D, exercise, bone-strengthening exercise. These are the first steps.

Then come the other bone-modifying drugs, so even if a patient has been told that they cannot get any of those drugs because of the side effects, they could certainly say calcium, vitamin D after discussing with their doctors, and they can regularly do some bone-strengthening building exercises sometimes it’s as simple as swimming, as simple as spinning, but those are like on the stationary bike, but those are extremely important activities to help build bone mass. 

Lisa Hatfield:

All right, thank you. Have you ever had a patient that has reached complete response that you said, Well, maybe you don’t need to continue on bisphosphonates, that ever an option for patients to not continue after a certain period of time?

Dr. Sikander Ailawadhi:

Again, excellent question. And, in fact, historically, all the bisphosphonate-related clinical trials had up to a two-year follow-up, so a lot of times we used to say, “Well, at two years we need to stop them because there’s no safety data beyond that.” But more recently, there are studies that have shown that even every three months of bisphosphonates is as good as every month. So if somebody has active bone-affecting myeloma, then their treatment can be given every month or every three months.

But if a person has gone into remission, and remember, the myeloma was the exciting event that was causing the bone loss, if there is no disease, if there are no active ones and the person is in good health, they are active…no bone-related issues. You’ve done imaging. Everything is good. I think it certainly it can be done that bisphosphonate can be stopped. And, of course, this needs to be actively discussed with the patient, frankly, other than having the side effect concern, if I can have a patient not coming for the treatment and they can spend that much extra time with their family doing what they want to…I think that’s a win-win. 

Understanding MGUS, Smoldering and Multiple Myeloma

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Understanding MGUS, Smoldering and Multiple Myeloma  from Patient Empowerment Network on Vimeo.

What is the difference between smoldering myeloma and monoclonal gammopathy of undetermined significance (MGUS)? Dr. Mark Schroeder defines these diagnoses and discusses how asymptomatic myeloma is monitored.

Dr. Mark Schroeder is a hematologist at Siteman Cancer Center of Washington University School of Medicine in St. Louis. Dr. Schroeder serves as Associate Professor in the Department of Medicine. Learn more about Dr. Schroeder.

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Transcript:

Katherine Banwell:

As a patient, engaging in your care starts with understanding your diagnosis, so I’d like to go through some definitions. What is multiple myeloma? 

Dr. Mark Schroeder:

Multiple myeloma is a blood cancer. It’s a cancer in particular of a blood cell called a plasma cell. Everybody has normal plasma cells in their body. It’s part of your immune system that responds to infections; they are also cells that respond to vaccinations.  

And when a plasma cell becomes a cancer, it often forms a cancer called multiple myeloma. And that cancer results oftentimes in damage to bones, low blood counts or anemia, potentially kidney problems, or possibly seeing high levels of calcium.  

Katherine Banwell:

What about smoldering myeloma? What is that? 

Dr. Mark Schroeder:

So, smoldering myeloma is a stage that happens prior to the development of myeloma that is causing organ damage. I talked about the damage to bones, kidneys, blood cells – that is called the CRAB criteria. The C stands for calcium, the R renal, A anemia, and B bones. We define myeloma by having damage to one of those four essential systems.  

Smoldering myeloma can happen when we actually see plasma cells that look like myeloma – that look like cancer cells, but they’re not causing the CRAB features of multiple myeloma. And there is a chance that sometimes that smoldering form of myeloma, it’s not causing any damage, but it can evolve and change into myeloma. 

Katherine Banwell:

What is MGUS? 

Dr. Mark Schroeder:

MGUS is a stage that happens prior to smoldering myeloma. We know that MGUS which stands for monoclonal gammopathy of undetermined significance – it’s a mouthful. That’s why we like to say MGUS.  

Katherine Banwell:

Yes. 

Dr. Mark Schroeder:

But it’s a protein that can be detected in your blood. Sometimes that protein does not mean you have a cancer. We can detect proteins like that in blood in patients who have, say, autoimmune diseases, and they’re at low levels. It’s just an immune response; it’s produced by those plasma cells that can be cancerous, but sometimes plasma cells grow because they’re stimulated – they’re overstimulated.  

And so, that monoclonal protein of MGUS can be detected in the blood, but we don’t see an increase in the number of cells in the bones that are classic for myeloma. But we know that about 1 percent of patients who have MGUS, every year, 1 percent might progress on to develop multiply myeloma. So, it’s a risk factor; it’s on the spectrum of disease from MGUS to smoldering myeloma to myeloma.  

Katherine Banwell:

Okay. And how is asymptomatic myeloma monitored?  

Dr. Mark Schroeder:

So, asymptomatic patients, I would consider those are the patients who have smoldering myeloma, so they don’t have the high calcium, the renal issues, anemia, or bone problems. And typically, those patients are followed up about every three to six months, depending on where they fit in kind of that spectrum of MGUS to smoldering myeloma to myeloma.  

Sometimes patients who have clinically identified myeloma and it presents very heterogeneous sometimes. They may not have a lot of organ involvement or organ damage, and maybe they’re frail, they’re elderly. And it may be appropriate also to observe patients who actually have some of the findings of myeloma, but the disease doesn’t seem to be as aggressive.