Recognising disease progression in MGUS and smouldering myeloma: Biomarkers, symptom monitoring and imaging.

The Tackling Early Morbidity and Mortality in Myeloma trial (TEAMM) trial recruited 977 newly diagnosed myeloma patients from 93 UK hospitals to assess the advantages and disadvantages of prophylactic antibiotics for the first 12 weeks. This paper analyses the 133 (14%) patients who had previously known precursor disease including monoclonal gammopathy of undetermined significance (MGUS) and smouldering myeloma (SMM), reporting the relative importance of blood-based biomarkers, imaging findings and symptoms in their management. Prior to progression with active myeloma, patients with precursor conditions had symptoms for five times longer than patients with no diagnosed precursor phase. Although only 29% of patients reported new myeloma-related symptoms developing after their first haematology appointment, 70% had a significant rise in paraprotein levels prior to progression. Likewise, risk scores for both MGUS and SMM increased prior to progression. Fractures occurred in 25% of patients despite being monitored for precursor disease. These fractures were difficult to predict as biomarkers lacked specificity and only 40% of patients reported back pain in combination with vertebral fractures. This study highlights the ongoing challenge of promptly recognising disease progression when using patient-reported symptoms and monoclonal immunoglobulin monitoring.