MRD Could Decide When Myeloma Maintenance Ends: Prerna Mewawalla, MD

Data from the ENDURANCE trial (NCT07456865) suggest that some patients with standard-risk multiple myeloma (MM) may not need indefinite lenalidomide maintenance, but Prerna Mewawalla, MD, director, Stem Cell Transplant Program, Allegheny Health Network, and associate professor, Drexel University College of Medicine, cautions those findings should not be extended to every patient. In this interview with The American Journal of Managed Care^®, she explained why high-risk disease may necessitate a more conservative approach.

Because high-risk patients were excluded from ENDURANCE, Mewawalla said nothing in the trial shows that stopping maintenance at 2 years is safe for a patient with high-risk features or genetics. For now, she continues maintenance treatment indefinitely in these patients and would wait for broader data in high-risk patients to be published before changing course.

Minimal residual disease (MRD) status may eventually help clinicians personalize how long treatment lasts. Mewawalla said, “I think MRD is the most logical tool that we have to personalize duration.” Smaller studies, including MRD2STOP (NCT04108624), have indicated that relapse risk is low in patients with sustained MRD negativity, although she noted these trials were very small. The study she is most eager to see is DRAMMATIC (NCT04071457). In the trial, patients receive induction and transplant, then are randomized to daratumumab- lenalidomide or lenalidomide alone. After 2 years of maintenance, patients who are MRD-negative are rerandomized to either stop or continue therapy while MRD-positive patients remain on treatment.

Mewawalla already uses MRD status in her practice, checking it before transplant and at 1 and 2 years after the procedure. It also factors into whether a patient proceeds to transplant. She believes MRD-guide discontinuation is where the field is heading, while still waiting on definitive randomized data. However, for high-risk patients, indefinite maintenance remains her approach until broader evidence arrives, and MRD-guided stopping is a promising goal.