Case 2: Evolution of Molecular Testing in Myeloma

EXPERT PERSPECTIVE VIRTUAL TUMOR BOARDNina Shah, MD:There is an ongoing MMRC [Multiple Myeloma Research Consortium] study that’s looking at patients getting 4 cycles of IRd [ixazomib/lenalidomide (Revlimid)/dexamethasone] consolidation after transplant. Then they are randomized to ixazomib versus lenalidomide maintenance. I think that might shed some light on this particular issue. I don’t know if we’ll be behind the times by the time we get the data, but, as of now, a lot of these patients are getting multiple novel agents, and so it will be pertinent to this time.

C. Ola Landgren, MD, PhD:Now, as we are moving into the future, we have more sensitive testing. We talk about MRD [minimal residual disease] testing with flow cytometry and sequencing. At our institution, we have both of those in real time. We’re also trying to develop blood-based testing. I think that the field is going to transform. Once we have the blood-based testing, there will be many new maintenance studies that will show that you maintain MRD negativity. I think that could be a new segue to development of new maintenance therapies. We may see subcutaneous shots of daratumumab or other drugs in the future. I think the field is going to just explode in this direction, in my opinion.

Nina Shah, MD:Yes. That’s good for our patients who can have more options. One last thing I just want to point out is that there are some ongoing trials regarding how long to treat with maintenance. There have been differences in where you get your maintenance therapy and for how long. The Spanish are looking at taking people who are MRD negative and randomizing them to continue maintenance or not. That’s going to be important from a resource utilization standpoint. If you don’t have to keep these patients on maintenance forever, it would be nice to be able to take them off.

Ajai Chari, MD:And to that point, if you’re going to do a test, do something with the results.

Nina Shah, MD:Yes.

Ajai Chari, MD:If you’re MRD positive or MRD negative, we’re not doing anything with the results. This is the first study that will act on the results, which will be really good.

Nina Shah, MD:Yes, I think it will be great.

C. Ola Landgren, MD, PhD:And I think the blood-based test will just continue to kind of deliver.

Nina Shah, MD:Yes. If you could do it on blood, I would be so happy. I think the patients would be, too.

Ajai Chari, MD:It will be like moving from immunoglobulins to an M spike.

Nina Shah, MD:Yes.

Ajai Chari, MD:Moving from respective complete response to blood-negative MRD.

Nina Shah, MD:Right. We’ll just do an eye scan at the end. Great. Well, this was a really great discussion about maintenance, and I hope that this was beneficial to everybody out there. We’ve talked about how there are data to show that maintenance can improve progression-free survival in various studies. And, if you combine that all together, you can get a showing of how it’s improved overall survival, although it’s important to look at the details of each of these studies. There are other options for maintenance for people based on tolerance and, potentially, cytogenetic risk. These are being explored in current clinical trials. Ultimately, the length of maintenance may be defined by more sensitive techniques of disease detection like MRD, maybe even in the blood.

Transcript edited for clarity.