New Standards in Myeloma Diagnosis Influence Major Changes in Care
Treatment options for myeloma have improved drastically in the past 10 years, and now updated guidelines will change diagnosis and treatment for many myeloma patients particularly those with smoldering myeloma. Will this affect you? Dr. Vincent Rajkumar explained the new standards to Myeloma Crowd founder Jenny Ahlstrom on the mPatient Myeloma Radio podcast Nov. 20. Dr. Rajkumar is Chair of the Myeloma, Amyloidosis, and Dysproteinemia Group at the Mayo Clinic in Rochester, Minnesota. On the podcast, Dr. Rajkumar explained key points from Updated Criteria for the Diagnosis of Multiple Myeloma the most recent publication from the International Myeloma Working Group (IMWG), the research arm of the International Myeloma Foundation (IMF), made up of about 180 researchers. The IMWGs major goals are to make sure patients receive the best possible care so that we provide the most accurate diagnostic, prognostic, and treatment guidelines that can be universally used, Dr. Rajkumar explained. The IMWG has not updated diagnostic criteria since 2003. Change was really needed based on numerous advances that have happened in the last decade or so in the treatment of multiple myeloma and related disorders, Dr. Rajkumar said. The number-one change: High-risk smoldering myeloma patients will receive a diagnosis of active myeloma earlier, as well as earlier treatment. In the past, most doctors waited until after end-organ damage, such as kidney failure or bone lesions, had occurred. Now that was fine when we did not have much in the way of treatment for the disease, he said. It is not fine when we have several exciting options which have more than doubled the survival of multiple myeloma. So waiting for end organ damage to happen is not going to serve our patients well because it means you are telling the patient I will treat you after you get renal failure or after you get lytic bone lesions or pathologic fracture but not before. Number two: Patients will receive more testing earlier in the disease, and smoldering patients will be watched more carefully. We became aware that we dont need to wait because we can actually, using new laboratory testing and modern imaging modalities, diagnose end-organ damage fairly early so we dont need to wait for skeletal survey to show changes or creatinine to change, Dr. Rajkumar said. We have computer tomography, CT scans, PET/CT which is Positron Emission Tomography which can identify lesions well before the skeletal survey can, and magnetic resonance imaging which is the MRI, he added. These imaging modalities can be used to diagnose myeloma early in the case of MRI, even before lytic bone lesions happen. Number three: Additional biomarkers will determine which smoldering myeloma patients are at high risk of progressing to active myeloma. We have accurate biomarkers that tell us if you look at patients with high-risk smoldering multiple myeloma that waiting is only going to cause harm and not provide any long-term benefit, he said. So the fact that we had accurate biomarkers now made it easier and important to change the criteria. In the past, doctors looked only for CRAB symptoms before treating smoldering myeloma. CRAB is an acronym that stands for increased calcium, renal failure, anemia, and bone lesions. Now, in addition to CRAB symptoms, doctors will watch for patients who have 60% or more plasma-cell involvement in the bone marrow, or a free light chain ratio of 100 or more, or more than one focal lesion on MRI. (These patients) are considered as having multiple myeloma even without symptoms and even without the presence of CRAB features, he said. So that will allow the diagnosis of multiple myeloma to be made early. The IMWG carefully looked at studies that supported the new criteria, Dr. Rajkumar said, in order to insure accuracy in diagnosis. Each of the three new biomarkers has more than three studies that show that patients with such features will progress with almost 80 percent certainty within two years and more than 90 percent certainty within three years. We did not want to use risk factors that would result in a large number of false positive diagnosis, errors in diagnosis, he said. We wanted to make sure was it was data-driven and there were at least two or more independent studies that validated these biomarkers. Among other changes in the lengthy publication: An updated definition for solitary plasmacytoma and updated follow-up recommendations for MGUS. I think the most important thing is we have set a threshold, a line in the sand so that the diagnostic criteria are living and evolve with time, Dr. Rajkumar said. For even more details on the new guidelines, read the entire transcript of the interview here.