Plasma cell dyscrasias (PCDs) are a group of clonal disorders characterized by the uninhibited expansion of a monoclonal population of malignant plasma cells. Plasma cells arise from B cells in the bone marrow and produce immunoglobulins that constitute the body's normal humoral immune response. The immunoglobulin molecule is composed of a heavy chain and a light chain. Plasma cells normally produce light chains in excess that do not bind to heavy chains to form a complete immunoglobulin molecule and instead enter the bloodstream as free light chains (FLCs). In PCDs, each abnormally expanded clone of malignant plasma cells produce an excess of either intact immunoglobulin or FLCs of a single type called a monoclonal protein (Mprotein) or paraprotein. The serum FLC (SFLC assay (the Freelite(TM) Assay, The Binding Site Ltd., Birmingham, United Kingdom) was introduced in 2001 to measure the FLC component in particular. The SFLC assay works by recognizing an epitope that is detectable only on light chains that are not bound to the heavy chain of the immunoglobulin molecule (i.e., FLCs) in the serum. It has been suggested that the SFLC assay could play an adjunctive role in screening, diagnosis, monitoring, and prognosis of PCDs in high-risk populations. The assay could allow for quantitative monitoring of response and remission after treatment and provide prognostic information, potentially reducing the need for frequent bone marrow biopsy for purposes of quantifying plasma cells, which is required as part of stringent monitoring for monoclonal gammopathy of undetermined significance (MGUS) progression to multiple myeloma (MM) or defining disease remission, and potentially could be used in conjunction with serum protein electrophoresis (SPEP) and serum immunofixation electrophoresis (SIFE) to replace urine tests that require 24-hour collection (urine protein electrophoresis UPEP] and urine immunofixation electrophoresis UIFE]), which could simplify diagnosis and disease monitoring. The SFLC assay may also be the only means of detecting a disease marker in some disease settings: nonsecretory MM, where SFLCs are often the only marker of the disease; AL amyloidosis (systemic amyloidosis in which amyloid A] proteins derived from immunoglobulin light chains L] are deposited in tissue), where low monoclonal protein (M-protein) concentrations may not be detected by means of conventional techniques; and light chain MM, where the M-protein consists only of FLCs. The following Key Questions are reviewed. KQ 1: Does adding the SFLC assay and the kappa/lambda ratio to traditional testing (SPEP, UPEP, SIFE, or UIFE), compared with traditional testing alone, improve the diagnostic accuracy for PCDs (MGUS, MM, nonsecretory MM, or AL amyloidosis) in undiagnosed patients suspected of having a PCD? KQ 2: As compared with traditional tests, how well does the SFLC assay independently predict progression to MM in patients with MGUS? KQ 3: In patients with an existing diagnosis of PCD (MM, nonsecretory MM, or AL amyloidosis), does the use of the SFLC assay result in different treatment decisions as compared with traditional tests? Does the use of the SFLC assay affect the management of patients by allowing for earlier institution of specific therapies? Does the use of the SFLC assay influence the duration of treatment? Does the use of the SFLC assay influence the type of treatment (e.g., radiation therapy)? KQ4: In patients with an existing diagnosis of PCD (MM, nonsecretory MM, or AL amyloidosis), is the SFLC assay better than traditional tests in indicating how the patient responds to treatment and of outcomes (overall survival, disease-free survival, remission, light chain escape, and quality of life)? KQ 5: In patients with an existing diagnosis of PCD (MM, nonsecretory MM, or AL amyloidosis), does the use of the SFLC assay reduce the need for other interventions (e.g., bone marrow biopsy)?
Hepatitis B is a highly prevalent disease with 350 million chronic cases worldwide and more than 4,000 incident cases in the U.S. in 2006. An estimated 2,000 to 4,000 deaths per year are related to Chronic Hepatitis B (CHB) liver diseases. The natural history of CHB is variable but generally indolent for many years to decades. Only 5% of acutely infected immunocompetent adults develop CHB. Demographic, clinical, and hepatitis B disease factors are believed associated with the development of CHB and poorer prognosis among those who develop CHB. Treatment goals include prevention of cirrhosis, hepatocellular cancer, and liver failure. Suppressing replication of hepatitis B virus (HBV) is believed a key process to achieving this goal. Hepatitis B treatments include nucleos(t)ide analogues that suppress viral replication and interferons, naturally occurring cytokines with antiviral and immunomodulatory properties. Six agents used as monotherapy or in combination have been approved, as of June 2008, for use in the U.S. A seventh, tenovir, was approved in August 2008. Two basic therapeutic approaches exist. A defined self-limited course (e.g., 4-12 months) followed by monitoring off treatment is generally used with interferon-based therapy. Long-term continuous suppressive therapy is used for other direct antiviral agents. Researchers have proposed clinical outcomes and biochemical, virologic, and histologic measures to determine an individual's risk for disease progression, identify candidates for treatment, and assess treatment effectiveness and harms. The Minnesota Evidence-based Practice Center (EPC) conducted a review to address the following questions for a National Institutes of Health (NIH) Consensus Conference related to Management of Chronic Hepatitis B in Adults. Consensus conference question 1. What is the natural history of Hepatitis B? EPC question 1. What is the evidence that the following population characteristics or clinical features associated with hepatitis B are predictive of hepatocellular carcinoma, liver failure, cirrhosis, liver-related death, and all-cause mortality? Consensus conference question 2. What are the benefits and risks of the current therapeutic options for hepatitis B with defined or continuous courses of treatment? EPC question 2a. What is the efficacy (or effectiveness) of interferon therapy, oral therapy, and various combinations in treating hepatitis B with defined or continuous courses of treatment? EPC question 2b. What are the known harms of interferon therapy, oral therapy, and various combinations in treating hepatitis B with defined or continuous courses of treatment? Surrogate outcomes of interest. Alanine aminotransferase (ALT) and/or aspartate aminotransferase (AST) levels, HBV viral load, change in Hepatitis B e antigen (HBeAg) status, hepatitis B surface antigen (HBsAg) conversion, liver biopsy findings (necroinflammatory activity or stage of fibrosis), and drug resistance. Clinical outcomes of interest include hepatocellular carcinoma, liver failure, cirrhosis, liver related death, all-cause mortality. Consensus conference question 3. Which persons with hepatitis B should be treated? EPC question 3a. Are there differences in efficacy/effectiveness of treatments for treatment na ve versus drug-resistant patients, chronic HBeAg-positive versus HBeAg-negative patients, or for other subpopulations? EPC question 3b. Is there evidence that specific subpopulations do not require treatment for hepatitis B? Consensus conference question 4. What measures are appropriate to monitor therapy and assess outcomes? EPC question 4. What is the evidence that changes in surrogate endpoints in response to treatment are reliable predictors of long-term resolution or slowed progression of disease? Patient Population: Adults (18 years of age or older), including elderly and members of racial/ethnic minority populations.
