What should myeloma patients do when a low level of myeloma protein remains detectable?

Should myeloma patients adjust their treatment plan? 

Dr. Brian G.M. Durie discusses the options available to myeloma patients who have a low level of myeloma protein detectable, and if this means patients should alter their treatment regimen. 


If a low level of myeloma protein remains detectable but is stable, it is not necessary to change treatment. Discuss these issues with your doctor. Understand the various types of myeloma tests. 

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This week’s “Ask Dr. Durie” comes from a patient who’s concerned about the result of MRD testing. He noticed that the MRD test showed a very low-level MRD-positive in the bone marrow after several months of treatment. And a very reasonable question which he asked is should he take new treatment? Take extra treatment? What should he do with the MRD positive result even although it’s at a very low level with just a tiny amount of myeloma protein left in the blood?   

And so, this is becoming a more and more common question, and very, very, reasonable. And, it actually has two types of answers. And so, the first answer is: If you’re on ongoing treatment, and the level of myeloma is continuing to drop month by month, this means that you actually have an ongoing response, and it may be, in the frontline setting, you could continue with another month or two of induction therapy, like a VRd or dara+VRd, or something like that. And then in the maintenance setting, it maybe means that you could continue with treatment for a few more months and you might ultimately become MRD-negative. So, basically, no change, continue and see if you do get that MRD-negative result over time. 

The second answer is: If things have reached a stable point, no improvement, just continuing at that low level with no further drop, this actually can be completely acceptable. Many patients do achieve a very, very, low-level stable remission, excellent remission, VGPR close to CR, and this is highly acceptable.   

And so, this can be maintained without pushing to take some extra aggressive new therapy. And in fact, what we recommended in that situation is that you know, you can save an additional alternate relapse regimen until we see an indication of change in the opposite direction, which could be months or maybe years until we might see, ok that very low level of protein is inching up a little bit or something else is changing, such that we need to consider another relapse treatment option.   

And so, you can see that these are detailed points and the BOTTOM LINE is: Please discuss these types of issues with your treating doctor. And, I would encourage discussion about two types of things. Number one, about the types of testing. There are different types of tests and you need to know the sensitivity level. But then also, some of the other details in terms of your own treatment protocol, if it’s reasonable to continue with your treatment, or look to even stop the treatment, look to maybe change the treatment at some point in the future. But, a very, very, important point being raised by this questioner this week. Please discuss it carefully with your doctor. 



Image of Dr. Brian G.M. DurieDr. Brian G.M. Durie serves as Chairman of the International Myeloma Foundation and serves on its Scientific Advisory Board. Additionally, he is Chairman of the IMF's International Myeloma Working Group, a consortium of nearly 200 myeloma experts from around the world. Dr. Durie also leads the IMF’s Black Swan Research Initiative®.


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