[Music] how is myeloma monitored so 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 times symptoms can tell us before anything else when disease is flaring up and we need to do a workup for it for possible relapse 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 and since it's just a blood test we can do that on a monthly basis we could 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 and that's how we tend to monitor myeloma the other thing that we can use for monitoring myeloma that's not blood test is by imaging studies so we do either a PET scan or an MRI or low contrast CT scan of the patient's body so that we can identify where there's tumors where those concentrations of active disease or disease that has been treated and then we can use that as a baseline and then monitored 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 repeat set of scans to see if there's any new lesions that we can identify now bone marrow biopsy starts 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 there at certain key points during the person's disease course when we first iagnosed it so that we can have a good idea of cytogenetics it has its risk categories the amount of disease that we have in a nice baseline of the tumor and then at different milestones when we suspect somebody has achieved our mission and then once they've achieved our mission we can subsequently repeat it periodically to make sure that there are still under mention 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 how does a doctor actually figure this all out well this business about plasma cells making protein protective proteins isn't lost when they become malignant these cells continue to make the protein the protein is now an abnormal protein because it's all being derived from one population of malignant weeds and this protein is detectable in the blood and in the urine and it's actually not the cause of the problem but what it is is a surrogate marker for what's going on in your garden in your bone marrow typically the more myeloma you have the more protein you make and it's critical for you to know your protein you need to know your protein it's a big deal in your monitoring these proteins are actually antibody proteins or immunoglobulin proteins they're proteins and these proteins are made out of two components a light chain and if you don't know light chain you're at a major disadvantage you need the no light chain and a heavy chain and your physicians use that as in direct measures of the activity of your disease and they actually use it to determine the depth of your response you're better now that's an indirect measure the only direct measure is the bone marrow so you can have two choices you can get your protein your heavy chaining your light chain measured every month well you can have a bone marrow every month short hands because really what we're interested in is how much myeloma is in the bone marrow but we use the protein measurements and surrogates because the working assumption since the weeds make the protein that the protein levels over time are a good reflection of how many weeds there are so if you're killing the weeds the protein should be dropping if the number of reads are unchanged the protein should be stable and if the disease is progressing then the protein should rise so it's very typical that every month or whatever you're monitoring interval is you're having a measurement of your life change there are two types Kappa and lambda you should know which one you have because that involved light chain is a big deal for your provider in terms of what is the activity of the disease there's also a heavy chain there are two types typically G and a or IgG and IgA that commonly will also be measured and if and it doesn't matter which you have you need to know which you've got because it's key to your overall monitoring over time and there's a third measure that and they're all good measures where you have a s pep and what your doctor will say and leave you bewildered we'll talk about your M spike and the M spike is just another way of measuring the protein it's different for the way in which you measure the heavy chain GA or the light chain Kappa lambda but it is a legitimate measure of the activity of the disease so the protein really isn't the problem the cancer cells the weeds are the problem the proteins a measure of the problem with one exception in 20% of patients the protein that's produced gels in the kidney it's produced in your garden and your bone marrow hits your bloodstream then the blood filters through the kidney and their light chains protein but then they gel and they damage the kidney so 20% of patients with multiple myeloma present because their kidneys are damaged in three-quarters of those that's completely reversible but still about 5% of patients even after effective therapy have residual kidney damage related to the gelling of the protein that's the only exception where the protein is the problem typically it's not the problem it's the marker it's what we use to determine how you're doing over time and we use it as a response and it's relatively simple because a lot of these things go back to the 60s if the protein went down 25% we say it's a minor response 50% it's a partial response 90% a very good partial response 100% the complete response and then there's some nuances in there about what does a hundred percent mean and ways to actually dive deeper to find out how really deep the response is but you need to know your myeloma protein when I do my second opinions I see a lot of engineers I don't know what it is about Rochester Minnesota and engineers that they come and they bring me an Excel spreadsheet that shows a graph of their protein and what treatments they've had a long time and I love them because then the next patient brings me 400 pages of useless material that it's very hard for me to sort through but when I see those protein numbers over time and what the treatments were it helps me immensely and believe me if it helps me it's going to end up helping you so preparing for that opinion I think it's kind of an say [Music]