Diagnosing and Managing Plasma Cell Disorders: Education Gaps in Primary Care Providers and Hematologist/Oncologists

Background: Diagnosis of plasma cell disorders (PCD) may be delayed due to generalized symptoms in patients. In fact, a recent analysis demonstrated that 2 years prior to diagnosis, 58% of patients with multiple myeloma (MM) indicated they had back pain and 34% had fatigue or weight loss [Goldschmidt N et al, JABFM 2016]. Furthermore, diagnostic criteria, staging, monitoring and management of PCD has vastly changed over the past decade allowing better methods for assessment and treatment options for patients with these disorders [Rajkumar SV et al, Lancet 2014, Palumbo A et al, JCO 2015]. To elucidate the clinical practice gaps in PCD, a study was undertaken to assess the ability of primary care providers (PCPs) and hematologists/oncologists (hem/onc) to appropriately diagnose, monitor, refer, stage and manage patients with PCD.

Methods: A continuing medical education-accredited clinical practice assessment survey was developed utilizing current evidence-based consensus guidelines and best practices in plasma cell disorders (http://www.medscape.org/viewarticle/866138 ). The assessment consisted of 20 multiple-choice, knowledge- and case -based questions that clinicians completed confidentially on-line starting on August 18, 2016. The questions assessed: diagnosis, risk stratification, and criteria to initiate therapy, monitoring, and management of patients with monoclonal gammopathy of undetermined significance (MGUS), smoldering multiple myeloma (SMM), and MM. Responses from physicians were de-identified and aggregated prior to analysis.

Results: As of July 11, 2017, 161 PCP and 281 hem/oncs participated in the assessment. Of the PCPs and hem/onc respondents, 45% and 38%, respectively, saw 1 to 5 patients with PCD per month. PCPs indicated that knowledge of appropriate tests was the biggest barrier in accurately diagnosing PCD (50%); whereas, hem/oncs indicated accessibility to tests was the biggest barrier (33%). Key findings included the following:

Diagnosis of PCD

Most clinicians were able to identify serum protein electrophoresis (SPEP) and immunofixation as necessary tests to order for diagnosing MGUS in a patient with elevated protein and mild anemia (79% PCPs and 94% hem/oncs). However, when presented with the outcome of laboratory tests, only 45% of PCPs were able to recognize that a patient may have a PCD and should be referred to a hem/onc. Based on the results of laboratory tests, less than half (42%) of PCPs were able to recognize that the patient had SMM or symptomatic myeloma and required referral. Only 24% of PCPs indicated that bone morrow examination, serum free light chain (sFLC), and testing for Bence Jones protein in urine were necessary to diagnose MM in a patient. Only 23% of PCPs and 50% of hem/oncs were aware of the new diagnostic criteria for myeloma that included sFLCs of involved/uninvolved ratio > 100.

Monitoring and Staging

Both PCP and hem/oncs struggled with the frequency of assessing a patient with MGUS for progression to SMM (32% and 30% of PCPs and hem/oncs, respectively, answering the patient should be seen at 6 months). 51% of PCPs and 74% of hem/oncs were able to identify the parameters of a patient with low-risk MGUS. Based on the results of test parameters only 29% of hem/oncs were able to identify the patient had revised ISS stage III SMM, and only 40% were able to assess that the patient had high risk SMM according to the Mayo criteria.

Conclusions: This educational research yielded important insights into clinical knowledge gaps for both the PCP and hem/onc. Both groups demonstrated education gaps in the areas of ordering and interpretation of tests, monitoring requirements, timing of referral, staging/risk assessment. Given the critical role that PCPs and hem/oncs play in the management of PCD, increased clinician awareness of gaps and tailored education is warranted in order to improve outcomes in patients with PCD.