When and how are bone strengthening agents (such as Xgeva or bisphosphonates) used in patients with precursor conditions and in patients with multiple myeloma, do bone lesions go away with treatment?
Treating any underlying bone issues with bone strengthening agents in patients with monoclonal gammopathy of undetermined significance (MGUS) or smoldering multiple myeloma (SMM) typically follows the same treatment guidelines for individuals with osteoporosis, which is usually treatment only once or twice a year. However, treatment for a patient diagnosed with myeloma is more frequent and typically once a month (for the first year) and that dosing schedule is too much for patients with MGUS or SMM. It is possible that some physicians may treat their patients with high-risk SMM more aggressively and use bone strengthening agents as they would for a patient with myeloma. However, the risk of side effects with these agents should be weighed against any benefit patients may receive. Talk to your doctor about what treatment is right for you.
In patients with myeloma, bone lesions (as viewed on imaging) do not go away even after treatment, but the lesions can be strengthened after treatment; for example, proteasome inhibitors like Velcade and Kyprolis are able to activate the osteoblasts (the cells that are responsible for building bone). Patients in remission have stronger bones due in part to the myeloma treatment and treatment with bone strengthening agents, but that doesn’t mean that they are no longer at risk of having a bone fracture, so patients need to stay vigilant about their bone health. For more information about bone disease see our FAQ post here and listen to our Myeloma Matters podcast episode on bone health here.
For a newly diagnosed monoclonal gammopathy of undetermined significance (MGUS) patient, what tests are needed?
Typically, an MGUS patient would have had a serum protein electrophoresis (SPEP) test (to look for abnormal protein in the blood) based on a symptom or laboratory abnormality that required the test. In addition to the SPEP, routine lab tests such as blood counts or assessment of kidney function can be conducted to ensure that the patient shows no evidence of myeloma-defining events such as: anemia (low hemoglobin or red blood cell counts), kidney failure, or high calcium levels. In the majority of patients with MGUS, no further testing (such as a bone marrow biopsy or advanced imaging studies) is needed. However, most doctors will proceed with additional testing for patients that meet certain criteria for high-risk MGUS—such as an M-protein level higher than 1.5 g/L, a non-IgG subtype of M-protein, or an abnormal serum free light chain ratio. It is important to note that there may be differences between cancer centers in the aggressiveness of the work-up for MGUS patients—some centers may choose to conduct a bone marrow biopsy and imaging tests in all patients.
Once an MGUS diagnosis is confirmed, patients have routine blood tests conducted frequently in their first year or two. Once an MGUS patient is considered stable, they may only need to go to their doctor for routine testing once a year.
How important is getting a second opinion for smoldering multiple myeloma (SMM)?
The field of SMM is an area with a lot of new research being conducted. Getting a second opinion—especially at a center that sees many patients with myeloma precursor conditions—after being diagnosed with SMM allows patients to get a full picture of the extent of their disease through appropriate testing and to know which clinical studies may be available.
