What is recommended for myeloma patients who are doing well on maintenance therapy?

This week's "Ask Dr. Durie" comes from a patient who wants to know what is the best testing and monitoring required when you are doing well on maintenance therapy or have come off therapy and are even being followed off therapy? This is a very important question because in addition to the standard testing required to monitor the status of myeloma, it is important these days to be aware of certain things that might occur. So, the standard testing includes testing for the monoclonal protein in the

serum and/or in the urine using SPEP or UPEP. Also, you obviously need to have the regular blood counts performed on the chemistry panel to make sure that the general conditions are good. However, what we are more alert to with patients going through many different protocols of treatment over the years is that in that response and maintenance period, there can be a relapse of the myeloma, which occurs with very little change in the SPEP or UPEP and maybe only minimal changes in the blood counts

or the chemistry panel. And so, in this situation, we now recommend that there needs to be a closer follow-up of the free light test to make sure that there is not an escape where there is something called a light chain escape, where the light chains start going up instead of just the serum myeloma protein or the urine protein. In addition, we need to be alert to any changes that the patient notices, if there is some new pain or swelling. It's important to be alert and get some extra imaging or

scans using PET/CT or MRI, or a whole-body CT scan, to see if any new lesions are popping up, even without minimal changes in the regular blood testing. The BOTTOM LINE these days is that we need to have a broader perspective on how we're viewing the patient to make sure that there are not subtle changes and that there is not the emergence of what is called either Bence-Jones light chain escape or even non-secretory escape where there is myeloma developing without the production of much protein

at all. And so, we are more alert than we have been in the past looking for perhaps soft tissue plasma chromas tumors or even changes in the blood with something like plasma cell leukemia. So, it is important to be particularly alert in the maintenance monitoring.