Published on January 28, 2020
- MRD helps medical professionals guide prognostic discussions, but not so much in terms of treatment decisions.
- Ongoing trials are collecting data on MRD testing to see where it fits in myeloma care.
- Assessing biomarkers or adverse cytogenetics is more useful for doctors today than just MRD.
Multiple myeloma experts Dr. Sagar Lonial, Dr. Krina Patel and Dr. Pei Lin sit down with patient advocate Jack Aiello to explain minimal residual disease (MRD) testing and results, and how it helps guide prognostic discussions. Watch as the expert panel discusses the current use of MRD for myeloma, ongoing clinical research and other recommended tests for patients.
This town hall meeting is sponsored by Janssen Biotech, Inc. and Karyopharm Therapeutics with additional support to our partner, Myeloma Crowd (MCR), from Takeda Oncology and Foundation Medicine. These organizations have no editorial control, and Patient Power is solely responsible for the content. It is produced by Patient Power in partnership with The University of Texas MD Anderson Cancer Center.
Transcript | How Do MRD Results Guide Myeloma Care Decisions?
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Dr. Lonial, we hear lots about MRD in terms of determining how much myeloma is in the body as a more sensitive way of checking things out compared with blood tests, but can you talk about MRD? Do you use it regularly? Do you use it to help guide any kind of treatment decisions? For that matter, should patients be requesting MRD testing if they’re not getting it?
That’s a tricky question.
I will tell you at our center, we do MRD testing and we collect the data to really pair it with longitudinal follow-up to understand where MRD testing can be most useful. I think there’s no question that patients that are MRD-negative have a better long-term outcome than patients that are not MRD-negative.
What we don’t know is whether you take somebody who’s MRD-positive and change their therapy to make them MRD-negative, do you actually change their outcome? You might say it’s only logical that you would. The reality is in many diseases, that is not the case because MRD testing really reflects what we call prognostic indications as opposed to predictive, meaning if you change it, you can actually change the outcome.
Those studies are currently ongoing now. One of the cautions – like I said, we collect the information on a lot of patients at different time points, as Dr. Patel indicated, but one of the concerns that I have when I think about using MRD negativity is one of my European colleagues will routinely get up at meetings and say if you’re high risk and you’re MRD-positive at one year, you won’t be alive in two years. I’ve got an entire clinic full of people that will prove him wrong.
The reason why our clinics are different from the clinics of this colleague in Europe is that we use three-drug continuous maintenance in our high-risk patients. And even if you’re MRD-positive, you can control the clone a much better way than you can if you have limited access because you can’t give three-drug continuous maintenance and you have to stop treatment in one year.
So, understanding what are the limitations of the data that’s out there telling us MRD is the answer is something that I think is a subtle point here. We may get to that point where MRD can drive decision making. At least right now, I don’t feel like I have enough data to use it that way. I don't know how you...
...same. We do it and it helps me guide prognostic discussions, but in terms of predictive, where I can stop maintenance, that’s another question I discuss with my patients. If you’ve done two years of maintenance where in Europe, everyone stops, in the U.S., we try to keep going.
Could that help us in the future decide if we can stop maintenance? That’s the exact clinical trials we’re waiting for, because we don’t want to under treat folks that are high-risk, but we also don’t want to overtreat folks that are standard risk.
And I think it’s important to realize in the CAR T-cell trials that you discussed, there are many patients who are MRD-negative at day 30 and are relapsing at day 90. So, MRD-negative is a path towards getting to elimination of the clone, but just because you achieve it doesn’t mean you can stop or you’re cured.
Sometimes I hear from our clinical colleagues tell me that I have this patient who has MRD and has been living in complete remission. From a pathologist’s point of view, I look at the smears and I can actually sometimes say that there’s a difference between patients who have MRD who relapse than who don’t relapse.
Many of those patients who have MRD that didn’t relapse, their myeloma cells don’t look so ugly. They don’t look so immature and so deviated from normal. They tend to look more or less like the mature plasma cells that we see. They’re sort of like the ones you see in like the MGUS or smoldering myeloma.
So, in that sense, I think assessing the morphology and other biomarkers like the adverse cytogenetics or FISH probably are more important than just the MRD itself in determining who is likely to relapse or not.