There’s a gap between the imaging services recommended for the management of multiple myeloma and associated plasma cell disorders, and what the MBS currently funds.

A Clinical Practice Statement by the Medical Scientific Advisory Group (MSAG) to Myeloma Australia has said that whole body plain X-rays are not recommended and instead are considered “inadequate and obsolete.”

Unfortunately, reimbursement in multiple myeloma is currently limited to whole body plain radiograph skeletal survey.

The Clinical Practice Statement said cross-sectional imaging is now the international standard of care for the diagnosis of bone disease – for all patients with a suspected diagnosis of multiple myeloma and smouldering multiple myeloma.

Lead author on the Clinical Practice Statement Dr Katherine Creeper told the limbic the diagnosis of multiple myeloma requiring therapy has recently changed to include not just lytic lesions but the earlier focal bone lesions.

“Essentially myeloma patients can get diagnosed earlier which means they can get treatment earlier and in the limited studies available that does correlate to increased progression-free survival,” she said.

Dr Creeper, from Sir Charles Gairdner Hospital at the time of writing the statement, said focal lesions have a low sensitivity on whole body X-ray.

“So really you need to have cross-sectional imaging with either CT or PET or MRI. This is the main reason we did the guidelines. We are trying to get MBS reimbursement.”

She said funding of cross-sectional imaging varied between states.

“I’m in WA and prior to writing these guidelines no tertiary centre in WA was offering a whole body CT for multiple myeloma patients whereas our colleagues in the eastern states were getting CT…the standard of care is different at different centres depending on what funding you can get.”

“It’s not really fair that myeloma patients in WA get different care to what is going on in Victoria or New South Wales, “ she said.

The Clinical Practice Statement recommends cross-sectional imaging should be offered to all patients with suspected multiple myeloma, non-secretory myeloma or intermediate-high risk asymptomatic disease.

It noted:

• Whole body low dose CT has a high sensitivity for the detection of bone lesions but is inaccurate for monitoring response to therapy
• MRI and PET-CT have a high sensitivity for detecting bone lesions and are helpful to monitor treatment response and to detect disease relapse
• MRI is the gold standard for the assessment of patients with suspected spinal cord compression
• Cross-sectional imaging should be performed in all cases of suspected solitary plasmacytoma to exclude further lesions
• Imaging is not recommended in patients considered to have low risk MGUS.

She said the main reason for imaging in MGUS was to upstage patients, particularly high-risk MGUS to an asymptomatic myeloma which made them eligible for PBS funded treatment if they have the bony lesions.

“And in the limited studies earlier treatment confers an improved PFS but for the low risk MGUS, the chance of finding any asymptomatic bony lesion is low so ultimately they are not going to have treatment anyway.”