When Should Myeloma Patients Consider MRD Testing?

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Where do minimal residual disease (MRD) tests fit in with multiple myeloma care? Myeloma expert Dr. Elisabet Manasanch and advanced practice nurse Tiffany Richards, both from The University of Texas MD Anderson Cancer Center,give expert perspectives on appropriate timing and frequency of MRD tests. Do treatment plans change if patients don’t achieve MRD-negative status? The expert panel also discusses treatment goals, evaluating response and further testing to help monitor patients. 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:

Just to be clear about the MRD testing, which becomes more and more sensitive, is that really kind of later in the process to do the MRD test? Where does it fit in?

Tiffany Richards:        

Yeah. So, usually, the MRD testing is not going to happen, until the patient is in a good remission. And so, generally, if the patient has achieved a complete remission, or if they have a small amount of residual protein, then, you may consider doing it. It really depends on the patient situation and where they are, in their journey. 

Andrew Schorr:          

Okay. What about do it more than once? Do you get a remission, but then, later somebody comes out of remission? And later, would you do it again?

Tiffany Richards:        

Generally, for a patient who is not on a clinical trial, at this point in time, we may recheck it. 

But for the physician I work with, we, generally, won’t recheck it because, at this point in time, it’s not like we would change—so, if a patient is on maintenance, lenalidomide (Revlimid), for example, and they achieved an MRD-negative, and now, they’re MRD positive, but everything else is still looking okay, their numbers aren’t changing, we wouldn’t necessarily change treatment, at that point. And so, it’s really going to be patient dependent. Sometimes, you’ll get them once a year, but, again, we don’t necessarily change treatment because a patient went from an MRD-negative status to an MRD-positive status.  

Andrew Schorr:          

Okay. Doctor, do you have a comment about that, about how often to do MRD or when?

Dr. Manasanch:          

Right now, if you are on a clinical trial, the clinical trial, basically, tells you when you’re going to test for this. If you’re not on a clinical trial, I’ll tell you when I do it. And I think also, a lot of physicians do it at MD Anderson, which is usually before our stem cell collection.

So, newly diagnosed patients, they come in. Okay, yes, we confirm this is myeloma. This needs to be treated. They get treated. The response rate for the treatment of multiple myeloma right now, with the therapist that we use at MD Anderson, the response rate is 100 percent. So, basically, everyone, maybe 1 patient in 300 doesn’t respond. So, we can say response rate is 100 percent. So, all of them are going to respond or almost all of them. And then, we get ready. Most of the times, most patients actually, in our center, about 80 percent of newly diagnosed patients choose to do an upfront autologous stem cell transplant, which means that they need their cells collected. 

And they proceed to get high dose melphalan, which is the medication that is given with that transplant process. And so, we check the bone marrow to make sure that, actually, we’re not going to pick up a lot of bad cells with the stem cells.

We check the bone marrow because we also want to have a good response, whatever response you have, usually, before a transplant. The marrow transplant outcome, again, for most patients, but generalizations do not apply so well to individual patients and their cases. So, every patient is different. But, usually, we check the bone marrow biopsy, before we do the stem cell collection. And then, the bone marrow biopsy, after treatment, usually includes a minimal residual disease testing. So, that’s definitely something that we kind of consent to do at MD Anderson. 

After that, it really is physician dependent. And it’s also patient dependent. So, all of us have a patient who wants to have a bone marrow biopsy every year and have minimal residual disease testing and seeing is it coming out of remission or not. Right now, there is no evidence coming from a clinical trial that that’s going to add any benefits. 

So, for example, doing a bone marrow biopsy once a year to see the minimal residual disease, whether it’s positive or negative. We don’t have information on that. However, from our experience, I believe that we will be doing this in the future. So, patients will get minimal residual disease testing in the future. And that will determine what we do with treatment. Why? What Tiffany said. First of all, it’s common sense. It’s a little bit of common sense. But all of the studies, all of the evidence that we start having from clinical trials will be showing is that the earlier you know and the earlier you do, the patient seems to have better outcomes. 

And that translates to smoldering myeloma, hopefully. So, now, I keep hearing more and more stronger voices about maybe treatment of that. So, that’s a big area also in myeloma. Why?

Because, as Tiffany said, they use the paraproteins, the electrophoresis, the M proteins. And then, they have the light chains. And the chains are a little bit more sensitive. So, then, now, we don’t wait. So, the patient has a paraprotein, an M protein, of 0.0, and then, we don’t wait for that paraprotein to be 1, if the light chains are high. If a patient has the light chains are going up, we treat the patient, if they’re consistently going up. We don’t want for the paraprotein to be a certain number. So, I feel like a minimal residual disease would be something similar. 

I feel like patients who will have the minimal residual disease, if they’re minimal residual disease is negative, they will have the testing done. And if we see that that starts to change, maybe the frequency of the MRD is increase. So, now, instead of doing your minimal residual disease testing every year, now, because it turned from negative to positive, now, we’re going to check it again in three months.

And guess what, if, in three months, that’s also higher, then, maybe you change the treatment, or maybe you start treatment. Now, that’s in the future. That’s what we are hoping to achieve, with all of this. And I think that a lot has done in the last few years. I believe that the Food and Drug Administration, the FDA, will actually approve minimal residual disease as an end point for clinical trials. So, basically, the response how drugs are going to get approved is not going to be just, if your remission is longer or if you live longer. But if you get drug A versus drug B, in a clinical trial, what is the percentage of patients that are minimal residual disease negative.  

This is going to happen. And so, right now, the use of MRD, I think, has either been limited to when we do our bone marrow biopsies in patients after treatment and the significance is prognostic. So, overall, for most patients, if you’re MRD-negative, it’s better than if you’re MRD-positive, again, for most patients.

And that’s all that we can say right now, today, is prognosis. But in the very near future, I think that we will do things like changing treatment. Maybe we’ll do things like stopping treatment. I don’t know. But we have a lot of studies that are looking at this right now. And they will report, in the next few years. So, this is where all of this is going. And right now, MRD is limited, I think, it prognosis. If you want to know your prognosis. And then, if you’re MRD negative, and you have to have it tested every year, you can. There’s nothing against it. What do we do with the information, if it turns positive? 

It’s a little bit ahead of the time where we have full answers. But it depends on the patient and the physician a lot. 

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 April 29, 2019