Monday, February 25, 2013

The Myeloma Blood Tests

This month's myeloma blood test results moved slightly off center. Since I don't recall previously discussing all of these tests, now would probably be a good time to do that.

I do remember mentioning the free light chain tests a year or so ago, the last time they attracted this kind of attention. This time the kappa free light chain number is a shade over the top of its normal range, while the lambda and kappa-lambda ratio numbers are normal. These tests are simply measuring the concentrations in the blood of these molecules, in milligrams per liter.

The other two tests seem more subjective in nature. They involve an examination by a trained analyst of "pictures" representing the behavior of blood proteins that have been subjected to certain processes.

In serum protein electrophoresis (SPEP), blood proteins are placed at one end of a agarose gel to which an electrical current is applied. Different proteins migrate to different locations in the electrical field on the gel; if monoclonal proteins are present in significant quantities, they will show up as a dense, narrow discrete band in the gel. Of course, depending on the patient's situation, this band may be more or less dense, and more or less narrow; this is not a binary, yes/no the patient does/doesn't have myeloma test. In my case, the analyst's comment says: "A very faint discrete band."

The immunofixation electropheresis (IFE) test attempts to further validate the presence of monoclonal proteins by identifying the heavy and free light chain components involved. The electrophoresis is repeated in five "lanes" on the gel; to each lane an antibody specific to one of the three heavy chains or two light chains is applied. An antibody reaction will cause a telltale precipitation band to be left behind in that lane. A band in a heavy chain lane, paired with a band in a light chain lane, identifies a specific type of monoclonal protein. In my case, the analyst's comment says: "A very diffuse IgG Kappa band seen."

Obviously, experienced hematologists could express differences of opinion regarding the significance of such phrases as "very faint" and "very diffuse", when used in this context. For his part, my oncologist, a phlegmatic, conservative sort, seems at least outwardly to be unimpressed by all of this. We will run these tests again next month, he says, and we will see.

Saturday, February 16, 2013

The Revlimid Paper Chase

No doubt you are used to getting a bit of paper whenever you go to the local pharmacy to pick up a prescription. Nowadays typically there is included with even the most seemingly innocuous of nostrums a "Medication Guide", printed on fan-folded tissue paper, that describes, unreadably and at considerable length, how to take the stuff; how not to take the stuff; all the bad things that could happen, maybe, if you dare to take the stuff; what to do and whom to call if any of these bad things happen; and so on.

But you never, ever read any of this mind-numbing material. Am I right?

News flash: This stuff isn't for you, the patient; it's for every one else involved in the process of delivering the products of the pharmaceutical-industrial complex. It's a liability-limitation mechanism. If something bad happens to you as a result of swallowing a few billion milligrams of Skeezix 100mg tabs, and an ambulance-chaser persuades you to sue the manufacturer, the defense's attorney will want to know whether the plaintiff actually read all this stuff, as required, and fully understood the risks involved. No? Well then: Your honor, this is clearly a deplorable example of the irresponsible misuse of a product the safety of which, when used as directed, has repeatedly been demonstrated blah blah blah.

Every 28 days the UPS man brings a little box to my door. It contains a plastic bottle containing 28 pills, and a quantity of paper. Some of the paper is packing material. But there is also the usual Medication Guide... and 16 standard 8-1/2x11 pages of additional stuff, mostly identical every time, and mostly recycled without much ceremony by yours truly:

An invoice (one page), in the quantity of my minuscule co-pay. The true invoice, for something like $10000, is not included; that is sent to the medical insurance company. I can see it only if I log into my account on the medical insurance web site.

"Important Drug Information" (4 pages). In effect a reprise of the material of the standard Medication Guide, but organized in a different manner, and "personalized" with my name, my oncologist's name, my pharmacy account number, etc.

"Medication Guide" (3 pages). Yet another copy, in a different format, of exactly the same material as the Medication Guide mentioned above.

"General Information about Cancer" (7 pages). Answers such burning questions as "Are there cancer treatment side effects?" (Ummm... Yeah.); and "Do I need to finish my chemotherapy even if I feel better?" (Nah, that's for sissies, pilgrim. But the last page warns against doing anything without asking your doctor first. So we're covered, counselor.)

And finally, a whole page of "Helpful Information Regarding Your Prescription", including such gold as "How do I convert the convertible cap to a non-safety cap for easy opening?".

What a comfort it is, to know this is possible.

Sunday, February 10, 2013


The multiple myeloma treatment arms race has really been heating up. Practically on the heels of FDA approval of Onyx's carfilzomib (branded as Kyprolis) comes approval for Celgene's latest thalidomide derivative, pomalidomide (branded as Pomalyst). Once again this entry is fenced about by theoretical restrictions (only for patients who have failed at least two other treatments, please) that will yield in practice to further research. Unsurprisingly given its lineage, pomalidomide seems to do better with a low-dose dexamethasone amplifier. Also unsurprisingly, these new agents are doing nothing to reduce the cost of treatment; both will run more or less the same $10000/month as my old reliable Revlimid.