Survey Finds Shift in Clinician Views of MRD Status in Treatment Decisions for Multiple Myeloma

A 2021 survey of clinicians who treat patients with multiple myeloma (MM) found a surge in acceptance of minimal residual disease (MRD) status as a guide for making treatment decisions, compared with a prior survey taken in 2018.

The survey results, published Monday in correspondence with Blood Cancer Journal, found that 60% of participants “would change at least one decision based on an MRD result,” and 54% would use both MRD status and disease risk to make decisions. An earlier version of the survey, conducted in 2018, found that only 37% of respondents reported using MRD to guide decision-making.

Evaluation of MRD is a comparatively new tool in MM care. Tests can now detect the presence of myeloma cells left in the bone marrow, even after a patient been treated and is in remission. These residual cells can lead to progression and relapse.

Authors Benjamin A. Derman, MD, of the University of Chicago Medical Center; Andrzej J. Jakubowiak, MD, PhD, of Tempus Labs, Chicago; and Michael A. Thompson, MD, PhD, Aurora Cancer Care, Milwaukee, Wisconsin; said the entrance of a new MRD test on the market and a revised survey format likely affected the results. They noted:

• Unlike the earlier survey, the 2021 version asked clinicians to respond to specific clinical scenarios in which MRD status could affect a treatment choice.
• FDA approved the clonoSEQ assay to assess MRD in September 2018, and it has become more widely available since first survey was completed.
• Multiple clinical trials have been published that include MRD-guided strategies.

The authors recruited clinicians to take part in the survey through Twitter between November 2020 and December 2021. A total of 90 respondents agreed to participate, 89 (99%) completed the core survey, and 68 (76%) responded to the clinical scenarios portion, which was optional. Most of the clinicians were from academic centers (76%), while 24% were in private practice or a hybrid setting. The median experience level was 10 years as a hematologist/oncologist, and the typical number of patients with MM seen per week was 20.

Most participants were from North American (65%), and Europe (23%); the rest were from South America (8%), Asia (2%), and Australia (2%).

The share of respondents who reported testing for MRD in a non-research setting, 64%, was in line with the percentage who said it affected decision making. Of the 35% (32 respondents) who did not use MRD, reasons cited were:

• inability to order MRD (22%),
• unsure when to assess for MRD (22%),
• lack of actionability (19%),
• cost (16%).

The authors presented findings for how clinicians responded to 5 specific scenarios and noted that 78% of the individuals would change at least 1 treatment decision based on an MRD result—suggesting that in real-world settings, willingness to use MRD status in decision-making is higher than clinicians may report. And in some cases, that could lead clinicians to scale back the use of expensive therapies.

“Interestingly, MRD status led to decisions being made in a bidirectional fashion. MRD positivity led to clinicians seeking to intensify therapy, while MRD negativity led to de-escalation of therapy,” they wrote. “This includes a strong preference for discontinuation of maintenance therapy in those with sustained MRD negativity and standard-risk disease.”

Among the limitations of the study, the authors noted the small sample size and the tilt toward academic clinicians. Finally, use of Twitter to recruit respondents may have led to a sample that was not representative of all clinicians treating MM.

Reference

Derman BA, Jakubowiak AJ, Thompson MA. Clinician survey regarding measurable residual disease-guided decision-making in multiple myeloma. Blood Cancer J. 2022;12:108.doi:10.1038/s41408-022-00705-6