PCPs Can Pave Way to Faster Diagnosis of Multiple Myeloma

Researchers of a new study are highlighting the role that primary care providers (PCPs) often have in facilitating early diagnosis of multiple myeloma (MM).

Offering considerations for the providers, the group highlighted the opportunities PCPs have to promote favorable outcomes through prompt diagnosis as well as help reduce racial disparities in disease.

“The majority of patients diagnosed with multiple myeloma initially present to their primary care provider (PCP). Unfortunately, the highly variable presentation of multiple myeloma often echoes signs and symptoms of conditions more commonly encountered by the generalist, such as diabetes, arthritis, and chronic renal insufficiency,” wrote the researchers. “This nonspecific presentation contributes to delays in both diagnosis and time to treatment. Early referral to hematology has the potential to improve survival and quality of life, underscoring the need for PCPs to be adept at recognizing typical signs and symptoms of multiple myeloma so that an appropriate diagnostic algorithm can be initiated.”

Emphasizing the variable presentation of the disease, the researchers highlighted common symptoms for PCPs to be aware of, including fatigue, bone pain, hypercalcemia, renal insufficient, anemia, and lytic bone lesions. Black/African American patients are more likely to exhibit markers of more aggressive disease, including anemia.

The researchers emphasized the importance of heightened awareness of MM for Black/African American patients in particular, as a recent analysis of 100 newly diagnosed patients found that more than half (62%) of patients who experience diagnostic delays are African American. Data has also established that black patients are less likely than their White counterparts to receive a complete initial diagnostic evaluation, including Revised/International Staging System testing.

In addition to anemia and hypercalcemia, blood testing of patients with MM may also show elevated creatinine, elevated total protein levels, low anion gap, low albumin, elevated lactate dehydrogenase, and elevated erythrocyte sedimentation rate.

Based findings from the clinical presentation and laboratory testing, the researchers emphasized the use of serum protein electrophoresis—an approach that measures serum M protein, the abnormal immunoglobulin secreted by malignant plasma cells in the bone marrow—and serum free light chain assays—an approach that identifies kappa and lambda free light chains, which can suggest monoclonality.

The researchers also highlighted the utility of combining serum free light chain testing with serum protein electrophoresis to improve detection rates, as 1 in 5 patients will have light chains only. By adding a third assay—serum immunofixation electrophoresis—providers will also have insight into the type of abnormal monoclonal protein and the light chain type in the serum, explained the group. Though the combination of methods does not increase the diagnostic sensitivity, it improves the diagnostic sensitivity for monoclonal gammopathy of undetermined significance by 8% and smoldering multiple myeloma by 0.5%. 

“In addition to utilizing appropriate and validated advances in technology, the ability of PCPs to improve multiple myeloma diagnostic speed and accuracy is likely to be informed by future research and influenced by heightened educational efforts. Most publications detailing time to diagnosis, impacts of diagnostic delay on outcomes, and disparities in access to novel and improved therapies (particularly within the Black/African American population) arise from data collected over a decade ago. Recent research presented at conferences have presented emerging data on these topics and their associated publications are eagerly awaited.”

Reference

Mikhael J, Bhutani M, Cole C. Multiple myeloma for the primary care provider: a practical review to promote earlier diagnosis among diverse populations. Am J Med. Published online September 20, 2022. doi:10.1016/j.amjmed.2022.08.030