BETA - How do doctors track myeloma treatment response?

Once treatment for myeloma begins, it's really important to keep checking how well it's working. Is the treatment shrinking the myeloma? Are symptoms getting better? Are there any new side effects? Doctors use regular tests to track all of this and make sure you're on the right path. In this Health Tree University lesson, you'll learn about the different ways your doctor monitors your progress and adjusts your care when needed. Monitoring myeloma can be done through blood tests, through imaging studies, through bone marrow biopsies, and obviously most importantly through the clinical exam that we do on a regular basis. A lot of the time symptoms can tell us before anything else when the disease is flaring up and we need to do a workup for possible relapse. What is involved in a clinical exam? So whenever somebody has suspected diagnosis of myeloma or they've already been diagnosed There's several things that we need to look at when we see them in the exam room. Some of them is just a physical exam where we check to see if there's any visible lumps or tumors that could be what's called a plasocytoma or lumps of tumors that are outside of the bone marrow. We also check to see if there's any evidence of neuropathy that could be caused by complications of the treatment that's used for multiple myeloma. We assess for other complications of diseases that tend to be associated or can come with myeloma like amyloidosis where we can see easy bruising. We see more incidence of neuropathy that has nothing to do with the treatment itself. We have other problems like poems that can also be seen in myeloma as a spin-off that has skin rash as well as hormone problems. So in the physical exam we make sure that people don't have any of these extra symptoms whether it be signs of heart failure with leg swelling or signs of kidney failure with leg swelling as well, shortness of breath, signs of skin involvement with stiffening of the skin with deposits of the amyloid protein or the M protein, easy bruising which can be done from the protein itself or can be caused by the treatments especially steroids that can make people prone to have more frail skin and then also assess for second cancers. People who are in maintenance therapy or who are exposed to lenalidomide or other inmates could be at increased risk of developing skin cancer. Not melanoma but squamous cell or basal cell so we want to make sure that there's no signs of potential complications there. Those are the main things that we look at whenever we do a physical exam. We want to make sure that they're not having any complications from the treatment and that they don't have any signs or symptoms of the actual disease. Bone pain, pressure, pain at pressure at different bone sites, extramedular disease. What blood and urine testing is done to monitor myeloma besides the physical exam? What are the myeloma markers are followed to monitor response or relapse? Routinely we will do peripheral blood testing and that would include the testing for an M spike or the monoclonal protein. Often we will do also the termination of the amino globulin so the IgG, the IgA and we will measure also routinely the serum for elachia. Now in the older days everyone also had routine measurement of the urine and there is still some debate about this in some centers and your doctors may want to do urine collections but in our particular center and in my practice in particular I have moved away from collecting urine on a routine basis to monitor for response so we do it mostly through blood testing. Myeloma can be monitored in several ways. Whenever somebody has a diagnosis of myeloma we have the ability to identify what's called a biomarker in the patient's blood or in the patient's urine and this is a very convenient way of being able to track what the cancer is doing in a patient without actually having to take biopsies every time. So we want to monitor the myeloma markers and since it's just a blood test we can do that on a monthly basis, we can do it every three months as frequently as we want. So whenever somebody has a diagnosis and is currently getting therapy we check it on a monthly basis and then once that patient achieves a remission and has established a remission for a long period of time we can space out the markers to just every three months. Myeloma markers are lab values and test results that doctors use to detect, diagnose, and monitor multiple myeloma. These markers help assess disease activity, treatment response, and possible relapse. Key markers are the M protein found in blood or urine, the free light chains detected in the blood, along with quantitative immunoglobulins. To learn more about these myeloma markers make sure to watch the Health Tree University lesson on this topic in the starting treatment course. We also want to monitor quantitative immunoglobulins to make sure that these patients are not at higher risk of developing infections by having low immunoglobulin levels. And that way we can always treat if it's needed or give preventive therapy if we need to do that. We also want to make sure that we do proper blood tests to make sure that the kidney function is doing okay, the level of hemoglobin platelets and white count is adequate, and that the chemotherapy is not causing a big suppression of the patient's ability to make blood. And also that puts the patient at risk of either an infection or bleeding or become very fatigued from the anemia. And that's how we tend to monitor myeloma. Besides blood and urine testing, how else is myeloma monitored? The other thing that we can use for monitoring myeloma that's not a blood test is by imaging studies. So we do either a PET scan or an MRI or a low-contrast CT scan of the patient's body so that we can identify where there's tumors, where there's concentrations of active disease or disease that has been treated. And then we can use that as a baseline and then monitor it with subsequent imaging studies during the course of the treatment. So whenever we think somebody has achieved a remission, we can repeat the scans. Or whenever we suspect that somebody might be progressing, we go ahead and analyze a repeat set of scans to see if there's any new lesions that we can identify. Now, we help ourselves through deeper testing in situations where we have questions about the accuracy of those markers or we may have a concern, for instance, of progressive disease. So in those circumstances, we may add imaging. For instance, we sometimes will do things such as a PET scan or a whole body CT scan. Is there a role for bone marrow biopsies in monitoring myeloma response? Bone marrow biopsies are another way of monitoring myeloma. And the bone marrow biopsies is a little bit trickier because it's more invasive. And patients don't like to be biopsied all the time. It's painful. It could be invasive. It can be inconvenient. But we do want to be doing biopsies periodically at certain key points during the person's disease course. When we first diagnose it so that we can have a good idea of what cytogenetics it has, its risk categories, the amount of disease that we have, and a nice baseline of the tumor. And then at different milestones, when we suspect somebody has achieved a remission, and then once they've achieved a remission, we can subsequently repeat it periodically to make sure that they're staying on remission and maintaining that remission. And when we do those tests, especially when we suspect remission, we can do additional studies that evaluate for MRD, which is a more thorough evaluation that can pick up up to one in a million cells for cancer. That's a very sensitive test that we're doing now in patients and can give us more information than just the standard complete remission that we normally are able to evaluate with pathology reports. Some situations we might do a bone marrow examination to look at what's going on with myeloma cells in the bone marrow in greater depth. Obviously, this is a more involved test. So it's not something we do on a regular basis. In fact, there's not even a predetermined schedule when you have to do bone marrows, but you do them more at times when there is a need for that additional information as you decide on what the next step should be. To learn more about bone marrow biopsies and MRD testing, check out the specific courses on these topics in the Monitoring Response to Treatment module. How often should monitoring tests be repeated when in active treatment and in remission? The frequency at which we perform tests depends on how the patient is doing and how aggressive the myeloma appears to be. The standard way of testing in general would be once a month. Once a month, we would repeat the free light chains, the M-spike, and the quantitative immunoglobulins. In addition to that, we like to measure what we call a complete blood count or the CVC, so we can monitor the hemoglobin for anemia, platelets, and white count, as well as what we call the complete chemistry, which includes a measurement of your kidney function as well as the calcium. So that's what we do on a routine basis. There are some circumstances where we may change this schedule. So for instance, if I have someone who has very aggressive myeloma or if I have someone who has newly diagnosed renal failure because they have multiple myeloma, I might do the free light chains with greater frequency. Sometimes even once a week, sometimes even more than that, when I need to get a very early signal that what I am doing is taking me in the right direction because it's very important. Otherwise, we may need to change treatments. So a classic example for this would be a hospitalized patient with new onset renal failure. Now on the counter side, if we have a patient who is on maintenance therapy, say with single agent linoleumide, the patient has no doses, has been doing well, and has been two years on maintenance, I think they don't really need to be tested monthly. So we will sometimes go as far as three months out between our tests. And of course, patients can always call or should call their clinical team if there's something that worries them or concerns them, and we can always do more testing in between. Usually every three months is sufficient. Understanding how treatment response is monitored in multiple myeloma helps you stay informed, empowered, and engaged in your care. From blood tests and imaging to bone marrow assessments, every piece of data plays a role in guiding your medical team and ensuring the best possible outcomes. To track your testing results, sign up for a Health Tree account. 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