Can opportunistic case-finding of paraproteins be clinically justified?

The addition of serum protein electrophoresis by laboratory staff upon finding an increased total protein or globulin appears to be practised widely in the UK. The criteria for assessing which samples are subject to electrophoresis vary considerably. They consist of initial objective laboratory data subsequently modified, somewhat subjectively, by other laboratory data and clinical details, but have often been chosen pragmatically. The aim of the practice is to identify patients with occult B-cell malignancies that warrant treatment. While it has been lent legitimacy in many cases by involving clinical haematologists in discussions, the views of other stakeholders, including other physicians and patients, have often not been considered, thus raising a number of ethical questions that need to be addressed. The practice is reviewed against both current knowledge of B-cell malignancies and monoclonal gammopathy of undetermined significance and criteria for screening, of which this forms a particular example. The arguments for and against addition of electrophoresis are finely balanced, partly because of the very limited outcome data available. We conclude that those currently following this practice should continue to do so, there is a need to establish outcome data as widely as possible according to standard criteria and there should be involvement of physicians, patients and national bodies in discussions about the practice so that the practical and ethical issues can be addressed.