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Published on June 3, 2021
What Is Biochemical Relapse?
In this segment from our recent Dinner with the Docs program, created in partnership with Atrium Health Levine Cancer Institute, host Cindy Chmielewski talks to Shebli Atrash, MD, and Mauricio Pineda-Roman, MD, both of whom are Hematologists/Medical Oncologists from Levine. Together they discuss the nature of biochemical relapse for multiple myeloma patients, when and how it occurs, and the tests that patients should receive.
Support for this series has been provided by Karyopharm Therapeutics. Patient Power maintains complete editorial control and is solely responsible for program content.
Transcript | Biochemical Relapse in Multiple Myeloma Patients
Cindy Chmielewski: Bonnie asked this question. So first, can we just talk about what does it mean to be a biochemical relapse? And then, what types of tests are the most important. Dr. Atrash?
What Is a Biochemical Relapse?
Dr. Atrash: Sure. So, a biochemical relapse is when we have those proteins that come from the plasma cell, they start going up in the blood. Very simple. Patient will be feeling fine. No issues, no CRAB features, no anemia, no renal problems, the calcium is normal and no new pain and bone pain, just the proteins going up. So that's what a biochemical relapse means. In terms of what testing to do, first, we have to make sure it's biochemical relapse, nothing else is going on, means we check the complete hematological profile. It's always better to do a bone marrow biopsy, because multiple myeloma learns how to fight us back. Multiple myeloma starts a lot of times, or the majority of the times, it's standard risk, but as it relapse and come back, it starts to learn how to fight us. And sometimes it converts to high-risk disease by capturing new genetic mutations.
What Are the Most Important Tests for Myeloma Patients?
So bone marrow biopsy is very helpful, but always this is a discussion. Sometimes patients elect to bypass that bone marrow biopsy, which is acceptable. I don't argue against that, but if possible, bone marrow biopsy will be the test that can tell me what genetic mutation, and then send it for genetic panel, FISH and cytogenetics. Those are the standard. And if we have access to more genetic testing, that would be fine with the GEP and other mutation analyses, but those analyses are not the standard of care as we are speaking right now, because they don't change our treatment or our management. Now, if we have high-risk features, you might make some modifications to the treatment. As Dr. Pineda was discussing, for my choice of the chemotherapy, we always aim to use the best drugs early on, not staggering our drugs, save the best for later. So that's where, for high-risk disease, we even do this even more with more aggressive treatments.
Cindy Chmielewski: Okay. So the bone marrow biopsy is important because that's where those genetic tests can be run off of. You can't do, as of now, who knows in the future, but right now those genetic tests can't be done out of a blood sample. So that's why you may want it, because your myeloma, in the beginning, may be standard risk, but over time may become high risk. Is that...
Dr. Atrash: That's correct, yes.
Cindy Chmielewski: And those fancy next-generation sequencing tests probably are best done in clinical trials, because right now the results to them won't change the standard of care that you get unless you're in a trial.
Dr. Atrash: Correct.
Cindy Chmielewski: Anything to add, Dr. Pineda-Roman?
What Else Should We Know About This Type of Relapse?
Dr. Pineda-Roman: Just one thing about the biochemical relapse. I think functionally, the protein produced by the plasma cells that we can detect in the blood, the M protein, is immunologically useless, as Dr. Atrash say at the beginning, but is medically helpful because that's how we detect biochemical relapse. So, we use it. Remember that the immunoglobulin has the heavy chains and the light chains. So, we not only follow the M spike, the immunoglobulin levels, but also the serum-free light chains, because some myelomas, either at the beginning or at relapse, may have a production of light chains. And in some rare occasions, at diagnosis and/or relapse, the myeloma can be non-secretory. These plasma cells may have forgotten how to make the abnormal protein. And we are having somebody with anemia, with a fracture, with kidney disease, and without a protein that we can see. So that's where the bone marrow becomes even more important if we are suspecting a relapse, because it may not show. It is rare, but it's something to keep in mind.