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ASH 2025 | Deciding when to discontinue maintenance therapy in a patient with multiple myeloma
In this video, Jesús San Miguel, MD, PhD, University of Navarra, Pamplona, Spain, discusses factors to consider when deciding whether discontinue maintenance therapy in a patient with multiple myeloma (MM), emphasizing that they must achieve and sustain measurable residual disease (MRD) negativity for at least two years before discontinuation can be considered. Prof. San Miguel highlights that the decision to stop treatment should also be based on the absence of high-risk factors, including late achievement of MRD negativity, high-risk genetics, and a high number of circulating tumor cells (CTCs) at diagnosis. This interview took place at the 67th ASH Annual Meeting and Exposition, held in Orlando, FL.
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Transcript
I think that the vast majority of myeloma doctors, and particularly the patients, don’t like continuous therapy, and now we need just to identify when to stop treatment. I think there is a risk to early, prematurely stopping the treatment. And we have seen this in smoldering, even, that myeloma requires quite prolonged treatment. And from a point of view, the duration of the treatment should be a minimum of two years after achieving MRD negativity...
I think that the vast majority of myeloma doctors, and particularly the patients, don’t like continuous therapy, and now we need just to identify when to stop treatment. I think there is a risk to early, prematurely stopping the treatment. And we have seen this in smoldering, even, that myeloma requires quite prolonged treatment. And from a point of view, the duration of the treatment should be a minimum of two years after achieving MRD negativity. And this MRD negativity should be sustained, maintained over at least two years. Because some people say, okay, MRD negativity for two years. No, this is not correct. This would be, once you achieve the MRD negativity, a minimum of two years. And I will be confident to stop if the patient has not high-risk because our group has reported and published already what are the risk factors for resurgence of MRD upon stopping treatment? And the risk factors are the following. First is late achievement of MRD negativity. If you achieve the MRD negativity in the early phase of the maintenance, be prudent. You need to continue quite a lot. Second, high-risk genetics. Third, high number of circulating tumor cells at diagnosis. And four, high tumor burden. If you put all this together and you are in front of a patient, you say, okay, you have not high-risk. The ISS was one or two. No circulating tumor cells at diagnosis. You achieved MRD negativity after induction or after transplant, or if you are not a transplant candidate, six months or nine months after the starting of the quadruplet, you achieved already MRD negativity. Then I will maintain another two years to demonstrate that it’s sustainability, and in this context, I will be happy to stop treatment.
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