Leveraging MRD Testing to Advance Value-Based Care in Multiple Myeloma: Emilie Aschenbrenner, PharmD, BCOP

At a recent Institute for Value-Based Medicine® event, Emilie Aschenbrenner, PharmD, BCOP, discussed how measurable residual disease (MRD) testing could enhance value-based care in multiple myeloma by guiding more personalized treatment decisions. Aschenbrenner, a hematology coordinator and clinical oncology pharmacist at Froedtert Health and the Medical College of Wisconsin in Milwaukee, noted that MRD is already used as a surrogate end point in clinical trials and could potentially inform real-world strategies such as tailoring maintenance therapy; avoiding overtreatment in patients with deep, durable responses; and intensifying therapy for those with less robust responses—similar to risk-adapted approaches in acute lymphoblastic leukemia. Trials such as MASTER (NCT03224507), MIDAS (NCT04934475), PERSEUS (NCT03710603), and GRIFFIN (NCT02874742) can be used as models for risk-adapted consolidation and maintenance decisions, according to Aschenbrenner. From a health system perspective, achieving MRD negativity earlier could also reduce infusion visits, hospitalizations, and overall costs by using the most effective therapies upfront.

However, Aschenbrenner emphasized significant barriers to routine MRD use in clinical practice, including high costs—particularly for next-generation sequencing—lack of standardized protocols, and inconsistent insurance coverage for repeated testing. Although academic centers may have more access, often through clinical trials or manufacturer support, community practices face greater challenges, limiting widespread adoption until costs decrease and testing becomes standardized as part of routine care.

This is the second part in a series with Aschenbrenner.

This transcript was lightly edited; captions were auto-generated.

Transcript

How might the use of MRD to guide treatment decisions in multiple myeloma contribute to improving value-based care?

There was a lot of discussion around this, as we know this can be used in clinical trials as a surrogate end point—that was widely adopted last year. Certainly, [we had] a lot of discussion on how we use this in the real-world setting. Overall, I think it's exciting. We talked a lot about having more effective therapies and quadruplet therapies and triplet therapies. We might be able to see a time where we're not using or offering autologous transplant for consolidation. But overall, as a panel, we thought we were not there quite yet.

We talked about, certainly, modeling after the MASTER trial, or there's a MIDAS trial for risk-adapted consolidation, also PERSEUS and GRIFFIN trials, where we can tailor maintenance, where not all patients may need a dual maintenance therapy for multiple years that could be very effective to implement MRD testing. Value, when we look at it from a patient perspective, [we like to ensure that] we're not over treating certain patients, but those that do not have as deep and durable responses, maybe we need to offer them more intensive treatment. We really model multiple myeloma, like we modeled treating a [patient with acute lymphoblastic leukemia].

Then we thought about value-based from a health care perspective. If we are able to get certain patients at different end points, like after induction or consolidation, for example, to have deep and durable responses and be MRD negative, then they don't have to show up to infusion clinic as often or have hospitalizations for infection, for example. All relateing back to using our best therapies upfront, [which] could be cost-effective long term.

What are key limitations and challenges associated with implementing MRD testing in clinical practice?

It's easy for us as an academic center at Froedtert in the medical college to offer patients these types of therapies, especially when they're covered on a clinical trial. Honestly, the companies that offer these tests, if they happen to be a payer and insurance company that wouldn't accept testing at a certain end point, after induction or consolidation, for example, generally, that can be what we'd [call] a write-off, or the company would offer to cover that. But we know that these are very costly tests, especially next generation sequencing.

There's certainly, when we look towards the future, if these are surrogate end points for [progression-free survival or overall survival], for example, that there'd be more economies of scale and the cost of this testing would go down. But right now, as it's not standardized in clinical practice, it's really hard even for our community partners to offer those routinely to all patients, and those patients that might not have access to large academic centers. That certainly can be challenging as it's not routinely standardized for standard of care, and not all patients’ insurance companies will accept repeated testing throughout courses of therapy and treatment.