One year after the FDA's Oncologic Drugs Advisory Committee (ODAC) unanimously approved minimal residual disease (MRD) as an end point for accelerated approval of multiple myeloma therapies, the research landscape has undergone a dramatic transformation. This regulatory milestone is accelerating drug development timelines and potentially giving patients access to novel treatments years earlier than previously possible.
Revolutionizing Clinical Trial Design
The ODAC's 12-0 vote in April 2024 has fundamentally changed how clinical trials in multiple myeloma are designed and conducted. According to Dr. C. Ola Landgren, professor of medicine and chief of the myeloma division at the Sylvester Comprehensive Cancer Center at the University of Miami, this shift represents a paradigm change in drug development.
"Instead of enrolling patients in a randomized trial that could take 2 years to complete and then wait another 10 or more years for the data to mature for progression-free survival, you could capture MRD results 1 year after randomization," explains Dr. Landgren. "That shrinks 10 to 15 years down to only 2 years of enrollment and 1 year to wait for MRD."
The implications for patients are profound. Successful therapies demonstrating higher rates of MRD negativity could receive accelerated approval, making new treatments available to patients approximately a decade earlier than under previous protocols.
Rapid Industry Adaptation
Pharmaceutical companies have moved swiftly to incorporate MRD endpoints into their clinical trial designs. "Many, if not all of the companies have implemented MRD as a coprimary end point," notes Dr. Landgren. "They have also included progression-free survival (PFS). The reason you see both is because not every drug may drive the disease all the way down to MRD negativity."
Companies with ongoing trials have negotiated with the FDA to amend their protocols to include MRD as a coprimary endpoint alongside traditional measures. This dual approach provides a safety net while still allowing for potentially faster approvals.
The CEPHEUS Trial: First Major Readout
The CEPHEUS trial (NCT03652064) has emerged as the first major study to read out with MRD as a coprimary endpoint. This trial evaluated newly diagnosed patients without transplantation, comparing a four-drug combination including daratumumab (Darzalex) with a three-drug regimen (VRd: bortezomib, lenalidomide, and dexamethasone).
"Johnson & Johnson took a calculated risk when they wrote the protocol when they put MRD as a coprimary endpoint, because at the time the study was going to read out, MRD had not yet been voted for by ODAC," Dr. Landgren explains. "Now, all the stars are aligned."
Scientific Validation of MRD
The path to MRD acceptance required extensive scientific validation. Dr. Landgren and colleagues published a comprehensive review in Blood Cancer Discovery in January 2025, detailing the evidence supporting MRD as a surrogate endpoint.
MRD negativity at a sensitivity of 10^-5 (detecting 1 malignant cell in 100,000) has been established as the minimum threshold for analysis, with some trials exploring even greater sensitivity (10^-6). Multiple meta-analyses have demonstrated that MRD negativity correlates strongly with superior progression-free survival and overall survival outcomes.
This correlation holds true regardless of patient population, disease setting, or treatment history—a critical factor in establishing MRD as a reliable surrogate endpoint.
MRD-Guided Treatment Approaches
Beyond its role in drug approval, MRD is increasingly being used to guide treatment decisions. The ADVANCE trial (NCT04268498), designed by Dr. Landgren, is investigating the addition of daratumumab to the KRd regimen (carfilzomib, lenalidomide, and dexamethasone) in newly diagnosed multiple myeloma.
In this innovative trial design, MRD status after eight cycles determines the next treatment step. "If patients are MRD negative, the protocol would keep patients on maintenance with a deferred transplant," Dr. Landgren explains. "If patients are completing the 8 cycles and they are MRD positive, if they have collected stem cells, the study would recommend a patient consider transplantation."
Results from this trial will be presented at the 2025 American Society of Clinical Oncology Annual Meeting.
International Implications and Future Directions
While the FDA has embraced MRD as an endpoint, international regulatory alignment remains a work in progress. Dr. Landgren and colleagues have submitted documentation to the European Medicines Agency (EMA), but formal decisions are still pending.
"From a drug company perspective, if you were to develop a study where PFS and MRD negativity are the end points here in the United States, and you get a readout for MRD after 2 or 3 years, if Europe has not yet approved MRD, then you have to wait for PFS," Dr. Landgren notes, highlighting the complexity of global drug development.
Expanding MRD Applications
The success of MRD in multiple myeloma has sparked interest in applying similar approaches to other hematologic malignancies. "The week after we went to ODAC, I got multiple emails and phone calls from different other disease areas asking if I could help develop MRD for many other diseases," says Dr. Landgren.
Researchers are also working to improve MRD detection technologies, including blood-based assays that could potentially be less invasive than bone marrow sampling, and imaging-based technologies that provide complementary information.
The Miami Myeloma MRD Meeting
To continue advancing the field, Dr. Landgren established the annual Miami Myeloma MRD Meeting eleven years ago, pledging to continue until the FDA approved MRD as an endpoint. Despite achieving this milestone, the meeting continues to serve as a crucial forum for discussing technological advances and clinical applications.
The 2025 meeting attracted nearly 1,000 participants, including in-person and online attendees from academia, industry, and patient organizations. "We continue to work on developing new technologies for tracking using blood-based technologies, and we also try to leverage the bone marrow–based technologies," Dr. Landgren explains.
The enthusiasm for this collaborative approach suggests that MRD will remain at the forefront of myeloma research for years to come, with potential applications extending far beyond its current use as a regulatory endpoint.
As the field continues to evolve, the integration of MRD into clinical practice and research represents one of the most significant advances in multiple myeloma treatment in recent years—one that promises to accelerate drug development and ultimately improve outcomes for patients with this challenging disease.
