My IgG myeloma protein has spiked, why is my doctor not recommending any new treatment?

March 7, 2020

This week’s Ask Dr. Durie comes from a concerned
patient, a patient who has been in remission for about four years right now, having received
stem cell transplant, and been followed off treatment. Everything has been going well, and actually
the patient continues to feel great. But at the time of last testing, it was noticed
that the protein having gone from zero, popped up to a level of 1.0 grams. So it had been a significant increase the
myeloma protein, but the doctor has said, “We’re not going to do anything about
that for now.” So the patient is obviously quite concerned
and wants to understand what this recommendation means. So what has happened is something called biochemical
relapse; this means the protein level has gone up a bit. In this low level, for it technically to be
called relapse, it has to go up by at least 500 mg, or .5 g. So in this case, it has gone up by more than
half a gram, which means that it is a biochemical relapse. But everything else is fine. There are no CRAB features. And so there is not an immediate need to treat
any active myeloma, because there is not any active myeloma. And so this is a very reasonable strategy,
but one we are looking at more carefully in recent years. The question now is if a patient is relapsing
from an excellent remission, how can we sustain and extend the outcome in this situation? And so we are now looking at very, very closely,
the value of early intervention and the possibility and advantages of treating people who are
in biochemical relapse. The idea being that there is a best outcome
if you start early, and have the best chance to knock the myeloma down to its lowest possible
level. And so this the BOTTOM LINE which is please,
please talk to your doctor carefully about these options. On the one hand, it is perfectly safe to consider
the “watch and wait “strategy just to see what is going to happen. Because sometimes the protein increases and
doesn’t change too much for months, and even sometimes years. However, if there is an upward trend, there
may definitely be a value in considering early re-treatment. And with such an excellent remission for four
years, there could be many excellent options. A second transplant, if this was desirable,
or maybe one of our new very, very effective combinations, such as daratumumab + Rev +
dex, or daratumumab + Velcade + dex, just to give a couple of examples. And so this is a very, very important decision
process right now, since we could watch and wait, or we could think about it carefully
and review the possibility of having an early intervention for the very best results possible.

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