Monitoring Multiple Myeloma: MRD Testing and Assessing Treatment Response

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Topics include: Treatments and Understanding

How is testing and monitoring of multiple myeloma patient outcomes changing? What can minimal residual disease (MRD) test results reveal? Noted myeloma experts Dr. Elisabet Manasanch and advanced practice nurse Tiffany Richards, both from The University of Texas MD Anderson Cancer Center, give their perspective on assessing successful myeloma treatment response, detecting cancer cells in patients and how MRD tests are performed. Watch now to learn more. 

This is a Patient Empowerment Network program produced by Patient Power in partnership with The University of Texas MD Anderson Cancer Center. We thank AbbVie, Inc., Celgene Corporation, and Sanofi for their support.

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Transcript

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Andrew Schorr:            

So, Tiffany, you’ve been working in myeloma for a number of years. You’ve done a lot of programs. The testing keeps getting better, right? But patients are saying to you, “How am I doing, how am I doing?” Like Cherie had the picture on the wall of the bathroom charting herself. Tell us about how testing is changing and this whole term of minimal residual disease. What does that mean?

Tiffany Richards:                      

Yeah, it’s a good question. So, when I started working here at Anderson 14 years ago, the light chains had recently been introduced. And we were starting to incorporate them into our response assessments.

But, predominantly, we were looking at SPEPs and UPEPs. But, certainly, the light chains would give us an early indicator, if a patient was starting to relapse. And then, over time, the response criteria have improved to now that we have minimal residual disease. And how I explain it to patients, I’m sure you’ve seen the slide with the iceberg. And patients, I think, relate to that. And I explained it to them that we pushed the iceberg far down below the level of detection that, with the most testing that we have, we can’t detect the iceberg anymore.

Andrew Schorr:                     

Okay. But that detection of cancer cells has become super sensitive now, right?

Tiffany Richards:                      

Yes.

Andrew Schorr:                     

So, okay, Dr. Manasanch, help us understand how are we assessing MRD?

So, if you are working with a Pathology Department or whoever, what tests are they doing to determine whether a patient has been treated successfully, basically?

Dr. Manasanch:          

So, we’re very fortunate here at MD Anderson because we have a fantastic flow cytometry lab. And so, we have minimal residual disease testing by flow cytometry. And that’s just sending aspirate of bone marrow, so just the blood and the aspirate, when you get a bone marrow biopsy done, and sending it for analysis through a special machine that really can look very carefully at the markers around the surface of the myeloma cells. And by looking at these markers, we can determine whether the plasma cells are normal or abnormal.

And we can determine how many, in that specimen, are plasma cells and then, how many are normal and how many are not normal. And so, if we do find any that are not normal, then, that’s what we call minimal residual disease in a patient that has been treated.

So, if you have multiple myeloma, and you have been treated for multiple myeloma, it is very common to do not just the blood studies and the 24-hour urine but also to do a bone marrow biopsy. And when you do the bone marrow biopsy, usually, that’s when you take a sample for analysis. Now, that’s what we do here at MD Anderson. Basically, we can detect one cell in hundred thousand, which is the sensitivity people are always talking about 10 to minus 4, 10 to minus 5, 10 to minus 6. So, ours here, with our flow cytometry testing, is 10 to minus 5, which is quite good.

And it’s probably almost the best that you can get with flow cytometry, in the bone marrow. And so, we get the result within a few days. And so, we’re very lucky with that. Now, there is also another technique. There’s a company called Adaptive Biotechnologies. And they have a test that is FDA approved. It’s called clonoSEQ.

And they have different versions. And the most recent one, actually, is quite potent. And they can detect cells one in a million. So, I’m not sure, Cherie, if I may ask you, in the test that you had done, did you have the clonoSEQ test done, with flow cytometry?

Cherie Rineker:                        

I just emailed my oncologist, the trial oncologist, about that. And he said that I was MRD negative, with the clonoSEQ was 10 to the negative 6.

Dr. Manasanch:          

Yeah. Because it’s very difficult to get the 10 to minus 6. So, the level of sensitivity is, basically, how many cells can you detect, in a sample of millions of cells, how many can you detect that are abnormal with myeloma. And so, with flow cytometry, it’s very difficult to get to one in a million. So, that’s why I suspected that’s probably done with the clonoSEQ assay. So, that test, basically, is available. The doctor has to send a sample to that company, Adaptive.

And then, what I’m not very clear on is how the billing is done. Now, for here at MD Anderson because we already have an assay that is set up, it really doesn’t cost extra to patients to do. We really do it through flow cytometry. And so, that’s really what we’re doing at MD Anderson right now is flow cytometry minimal residual disease. It works pretty well. We know, from many studies, that it is predictive of how long a remission will last, in most patients. However, each patient is so different that this is something that, whether, in your particular case, you need minimal residual disease or not is something that really has to be addressed with every patient because every patient is a little bit different.

And one of major limitations of minimal residual disease is that it comes from the bone marrow. And the bone marrow is a blind biopsy, right. And so, people can have other things in other places, and we don’t see them.

Now, it seems that, for most patients, it still works pretty well. But if you have a collection of plasma cells somewhere else that is not in that specific location where we do the bone marrow, that’s not going to show up. And so, that’s one of the limitations of this. And what we try to do with that is you can combine some imaging with the bone marrow test. And that even has a better prediction probably. So, you can do like a whole body MRI or a whole body PET CT. And then, you can look to see are there any lesions, anything that we’re not looking at the bone marrow.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

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Page last updated on March 25, 2019