Next Steps for Using MRD to Guide Maintenance Therapy for Multiple Myeloma

Ben Derman, MD, assistant professor of medicine at the University of Chicago Medical Center, discusses next steps for using minimal residual disease (MRD)-guided discontinuation of maintenance therapy in patients with multiple myeloma.

The prospective MRD2STOP trial (NCT04108624) permitted patients receiving lenalidomide (Revlimid) maintenance therapy for multiple myeloma to stop based on MRD negativity at the 10^-6 threshold. After 15 months, only 5 out of 38 patients regained MRD positivity and 2 had biochemical progression.

According to Derman, longer-term follow-up for this study is crucial to see if patients can stay off therapy and remain MRD-negative at 24 or 36 months. This could show that multiple myeloma will not relapse in this subset of patients, and they are potentially cured. Another aspect that is promising is reducing the cost of therapy, as lenalidomide can cost $18,000 a month. Derman calculated that in the 507 months of observation among these 38 patients, $9 million were saved, not counting the costs of the trial and patients who needed to reinitiate therapy.

In addition to longer follow-up, Derman says that investigators are collecting quality-of-life surveys and creating a formal cost-saving analysis. They are also trying to use peripheral blood tests to reduce the need for bone marrow biopsies for MRD testing.

TRANSCRIPTION:

0:08 | What's going to be important is to see what happens beyond a year, what happens at 24 months, what's going to happen at 36 months, and try to see, is 10^-6 negativity going to be able to tell us who can come off of therapy safely without worrying about their disease coming back? That may help us define patients who may be cured of their myeloma, which is a controversial concept. I think what's encouraging is the fact that when you think about $18,000 a month for lenalidomide right now in the United States and you multiply that by 507 months of observation that we had just in this short follow-up on the study, we actually saved about $9 million US dollars from stopping lenalidomide alone. Now, you have to factor in the cost of testing and reinitiating treatment in patients who relapse, but that's still going to lead to significant cost savings on the order of millions of dollars.

1:18 | What we're looking for is longer follow-up right now. We are actually collecting quality-of-life surveys that we hope to be able to share soon, do a formal cost savings analysis, and then also try to incorporate some peripheral blood tests that might be able to help circumvent the need for bone marrow biopsies in the future.