Myeloma Expert Stresses Significance of Appropriate Diagnostic Work-up

Reed Friend, MD

Appropriately diagnosing a patient with multiple myeloma is a key point in their potential treatment, which has been further characterized by the revision of the International Myeloma Working Group criteria for the diagnosis of myeloma.

The diagnostic criteria, which was updated in 2014, addresses other clinical features aside from the CRAB criteria—defined as increased calcium level, renal dysfunction, anemia, and destructive bone lesions—for patients to be considered for treatment. These also include biomarkers of 60% or greater clonal plasma cells on bone marrow examination and a serum involved/uninvolved free light chain ratio of 100 or greater.

“Sometimes, we see patients with these factors that [show that] maybe [they] should be treated a little bit earlier,” said Reed Friend, MD.

OncLive: You spoke on diagnosis and prognosis of multiple myeloma. What were the highlights of your presentation?

Friend, a medical oncologist in hematology and medical oncology, of Levine Cancer Institute and Carolinas HealthCare System, discussed the revised steps in diagnosing patients with multiple myeloma and prognostic factors, as well as existing challenges and hopes for the field’s future in an interview during the 2017 OncLive^® State of the Science Summit^TM on Multiple Myeloma. Friend: In terms of the diagnosis and prognosis of multiple myeloma, the biggest thing is making sure that local providers and physicians who see patients with suspected myeloma are appropriately working them up. A lot of patients can be missed in terms of diagnosis if you are not ordering the right tests. In terms of work-up, the most common things people forget to order are the serum-free light chains and the urine studies. With imaging surveys, some people miss [myeloma].

Even on a skeletal survey, you can only detect up to 50% to 70% of the bone damage that occurs. You have these early damage things that occur on the bone, in the marrow, from myeloma. That is not being detected on the skeletal surveys. If you are suspecting damage in the bones, then you would want to further work it up with the whole-body MRI, where you can get a more sensitive approach to the marrow damage.

What advice can you provide to community oncologists on ensuring they are getting the appropriate work-up for their patients?

Also, plasmacytomas can occur. You would really only be able to see that on something like a PET/CT scan, where you see the hypermetabolic activity happening. It might be more of getting the right tests done, being as comprehensive as possible, and not missing things. Another thing that is important, and has recently been updated as of 2014, is the diagnostic criteria has been revised to include bone marrow involvement of plasma cells greater than 60%. Even if you don’t meet those classic CRAB criteria—the hypercalcemia, the renal dysfunction, anemia, the bone lytic lesions—if you have someone who has bone marrow with greater than 60% plasma cells, they need to be treated.

What are your thoughts on a multidisciplinary approach for patients with multiple myeloma?

Another thing that came out with the revised criteria is, if you have greater than 100 serum free light chain over the involved/uninvolved ratio—so, that is important to take into consideration. If you find more than 1 lesion on the MRI, the PET/CT scan, then the patient needs to be treated or considered for treatment.I have always been about the multidisciplinary approach. I saw a couple of patients [recently]; 1 of them has other comorbidities aside from their newly diagnosed multiple myeloma. And, they’re asking about diets. We have a dietician in our clinic who meets with our patients and helps them configure what kind of diet would be best for them.

You also spoke about bone health and supportive care at this meeting. Can you hone in more on that arena?

What ongoing studies are you specifically looking forward to seeing the results of?

What looming challenge in multiple myeloma can we start to overcome?

What does the field of multiple myeloma look like to you over the next few years?

Social work is really important, especially when you’re diagnosed with cancer. [Myeloma is] something that may not be curable right now but, in the future, it will be. It is important to take the patient as a “whole person” and not just focus on that diagnosis. We really do need a multidisciplinary approach. In terms of bone health, one of the biggest complications of multiple myeloma—since it is a cancer of the bones—is bone pain. A lot of patients present with bone pain and broken bones and impending fractures. I just saw a patient last week with newly diagnosed multiple myeloma and his symptom was severe, debilitating back pain where he couldn’t even get out of bed; he was in so much pain. Bone health is one of the most important things in terms of stopping that inverse mechanism. Myeloma wreaks havoc on the bone; it inverses the natural process of how you build bones and destroy them. It really accelerates that osteoclast activity. One of the most exciting things that are coming around in multiple myeloma are the monoclonal antibodies, such as daratumumab (Darzalex). We have a phase III trial that is looking at daratumumab in addition to standard upfront treatment of lenalidomide (Revlimid) and dexamethasone or bortezomib (Velcade) and dexamethasone in transplant-eligible patients with myeloma. That would be a great study to see. We already know such exciting data exists on the relapsed/refractory patients, but what about in the upfront setting?More awareness. In multiple myeloma, there needs to be more awareness in the community. I am seeing so many newly diagnosed patients who have never heard of this condition. A lot of people make fun of me because, while it’s amazing that breast cancer, prostate cancer, and lung cancer have so much awareness, I wish that multiple myeloma was known [as well] in the community. That is one of the biggest and most important things that I hope we can bring to our community and [eventually] find a cure. I see there being a cure in our future. I don’t know if it is in 5 to 10 years, but I do see a lot of progress. I do think more awareness in the community is important. However, I do see a cure, I do.

Rajkumar SV, Dimopoulos MA, Palumbo A, et al. International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma. Lancet Oncol. 2014;15(12): e538—e548. doi: 10.1016/S1470-2045(14)70442-5.