Should there be screening for precursor conditions as part of routine care?

Should there be screening for precursor conditions as part of routine care?

There has been two studies that have been done to date, the iStop study in Iceland where they screened basically their whole population, 80,000 people, and they're following them to date. And we decided on using a more risk stratified approach. We said, let's screen people who are at risk of developing multiple myeloma so that we're not screening the whole general population. So we're screening people who are African-American or of African descent or people who have a first degree family member with a plasma cell or a blood cancer. So think mom, dad, sisters, brothers, because now they have a much higher risk of developing a monoclonal protein. And we also use a much more sensitive test called mass spectrometry, instead of using the traditional methods of serum protein electrophoresis. And by doing that, you need to ask the question, is there a benefit for someone to be screened? And the answer is, if I can find MGUS at an early stage, we like potentially treat that patient to prevent progression and change the survival. And if the answer is yes, then we should be screening everyone instead of waiting for it to be incidentally found. Now I think of cancer screening saves lives and there are four cancers that we currently screen for, breast, colon, as well as cervical cancer. And if you think about it, why are we not screening with a blood sample to look for monoclonal gammopathy or other blood cancers? Once we show that indeed we can do it, and because we can treat those patients, think about smoldering myeloma, we can treat those patients as changed their survival. And you can notice that smoldering myeloma, unless we find it either incidentally, because by chance your doctor tested it or by screening. So if you screen and you won't do anything until they are at the point of changing from that normal phenotype to a malignant phenotype from there is no chance of progression to yes, there is a chance of progression. I would do something. That's when you could potentially cure them. But you also need to screen them to find them so that it's not by pure chance that your doctor found it. It's truly because you're at risk and then they found it. I would also not advocate to screen the general population because still the numbers are low despite this showing that the numbers are much higher. You need to really think of who is at risk and how to stratify that so that we're only screening people at risk and not the gender of population. And it's the same for colon cancer and for breast cancer and cervical cancer. We don't screen everyone with screening either at a certain age or people who are really at high risk. Lung cancer is the fourth one, especially for smokers. So as we improve on it, we will get to screening. It's an easy, simple test. It’s highly specific and sensitive, which is the mass spectrometry or serum protein electrophoresis. It's easy to do, it’s a blood test. Risk stratify patients and you can do something about it. So it meets all the criteria of a potentially valuable cancer screening tests. So myeloma is obviously a rare disease. So when you think of a screening test, you think about, first of all, what is the chance I'm going to find something. And then the second part is if I do, am I going to have an intervention that's going to make a difference in terms of people living longer. So it's a sort of a cost benefit analysis. And I think in myeloma, if you think about it, first of all, we don't even have agreement on people of smoldering myeloma they should be treated. So therefore, going back to screening for them, I think is not necessarily something we should do. Having said that, there is an initiative in Iceland where they are obviously screening their entire population for M proteins. And not surprisingly, you find it in a percentage of the population because as you get older, it's not uncommon to develop monoclonal gammopathy or abnormal M proteins. But again, in the absence of showing that finding, it isn’t going to make any difference in your life. I don't think screening in that sense is is warranted. There are certain populations maybe, for example, we and people have talked about if you have multiple first degree relatives with it because there is some familial, slightly increased risk potentially perhaps, patients who had a develop it at a younger age and African-American again, then you've sort of had a couple things to think about. If you're a first degree relative or something like that, maybe. So I think that's a little bit more individualized, but certainly not generalized population screening. We're not ready to do that.