Introduction: For years our large academic medical center faced an issue of access to myeloma physicians at main campus due to the increasing number of referrals for monoclonal gammopathy of undetermined significance (MGUS). We hired additional advanced practice providers (APPs) at main campus and several regional sites, with MGUS referrals triaged to their clinic. Due to concerns regarding variation in experience with work up of monoclonal gammopathy we created a structured method to approach all MGUS consults. This included standardized educational materials with recommended workflow, the “MGUS Care Path” and a consultation template in the EMR. In August 2021, we formalized a MGUS tumor board focused on discussing cases with possible clinical significance.
Methods: These cases are presented to main campus plasma cell disorder experts, including three physicians and our APRN/PhD. We meet every 1st and 3rd Monday of the month to provide educational support and standardization for work up of MGUS to avoid missing any cases of clinical significance. We present here our outcomes based on over three years of data from our MGUS tumor board.
Results: From August 2021 to February 2025, our APPs saw over 800 referrals for MGUS. We discussed 267 of these patient cases based on clinical findings or investigations concerning for monoclonal gammopathy of clinical significance (MGCS). Based on recommendations from the MGUS tumor board we diagnosed a variety of disorders driven by the monoclonal gammopathy. These include type 1 cryoglobulinemia, IgM neuropathy with anti-MAG, TEMPI, warm-autoimmune hemolytic anemia, Schnitzler’s disease, smoldering and active myeloma, marginal zone lymphoma, myelodysplastic syndrome, chronic lymphocytic leukemia, light chain amyloidosis, proliferative glomerulonephritis with monoclonal immune deposition. Of the 267 cases, 75 (28.0%) were referred to physicians at main campus, with 25 (9.4%) requiring treatment.
Conclusions: We previously reported our tumor board findings after 147 patients with 41 (28.0%) found to have MGCS and 16 (11.0%) needing treatment. It was initially surprising that 1 in 4 cases were confirmed MGCS based on tumor board recommended work up. This update after over three years shows consistent distribution, with ~25% MGCS cases. The majority of MGUS patients continue to receive care with our APPs. This allowed the myeloma program at main campus to grow. We hired three additional myeloma physicians in the past two years, expanded the clinical trial portfolio and improved access to cell therapies and physician consultations. We continue to provide CME for attendance at the MGUS tumor board for both APPs and physicians. The tumor board remains a reliable method to triage MGUS consults, providing improved access to physician specialists, while minimizing the risk of missing cases of MGCS. We have also implemented a similar model for anemia consults creating more access to main campus classical hematology providers.
