MRD Testing for Multiple Myeloma Post-transplant May Lead to Improved Care, Outcomes

Testing for measurable residual disease (MRD) in the post-transplant setting in multiple myeloma (MM) is conducted predominantly in the research setting.

However, new technology is changing MRD testing and it may be moving into the clinic in the not too distant future. Once it does, clinicians hope to answer the question: Do all patients who achieve a stringent complete remission after autologous stem cell transplantation require post-transplant maintenance chemotherapy?

“MRD testing could help guide providers in this situation and others,” said Robert Cornell, MD, MS, an assistant professor of medicine in the Division of Hematology and Oncology at Vanderbilt University Medical Center in Nashville, TN.

Dr Cornell and his colleagues have been studying the growing number of increasingly sensitive methods of MRD testing, including multi-parametric flow cytometry, polymerase chain reaction, next-generation sequencing (NGS), and several imaging modalities. The researchers conducted a literature review involving the current methods for detecting and monitoring MRD in the post-transplant setting.¹

Novel therapies and autologous stem cell transplantation have led to significant improvements in progression-free survival and overall survival in patients with MM in recent years. However, Dr Cornell said most patients eventually relapse and this appears to be due to persistent low levels of disease in the bone marrow.

“There are multiple potential options for MRD testing. The currently favored modality is with the use of NGS, for example ClonoSEQ. The goal of MRD testing in myeloma is that it should be highly sensitive, easily accessible, cost-effective and standardized. Currently, I believe sequencing techniques best fit these parameters. As MRD is more readily implemented into clinical trials and eventually clinical practice, these goals will be increasingly achieved,” Dr Cornell told Cancer Therapy Advisor.

He said 1 of the main potential pitfalls of MRD testing is that it does not have a meaningful clinical endpoint which affects management. Dr Cornell said even among patients who are MRD negative, many eventually relapse. He said it will be important to understand the timing of these relapses compared to being MRD positive. That may help better guide clinicians determine when it is appropriate for a change in management.

“As with any non-standardized testing, cost also is a concern and should be taken into consideration when ordering such testing,” he said. “It is also important to consider patients’ anxiety with such testing. However, in most cases I have not found this to add additional anxiety beyond the usual testing for myeloma disease status so long as patients are well informed about the test and interpretation of the results.”