Medical Policy

Policy Num:      11.003.111
Policy Name:    Next Generation Sequencing for the Assessment of Measurable Residual Disease
Policy ID:          [11.003.111]  [Ac / B / M+ / P+]  [2.04.147]


Last Review:      January 09, 2024
Next Review:      January 20, 2025

 

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Next Generation Sequencing for the Assessment of Measurable Residual Disease

Population Reference No.

Populations

Interventions

Comparators

Outcomes

1

Individuals:

  • Who have B-cell acute lymphoblastic leukemia who are being monitored for residual disease following treatment

Interventions of interest are:

  • Next-generation sequencing for measurable residual disease at a threshold of 10-4

Comparators of interest are:

  • Flow cytometry
  • Polymerase chain reaction

Relevant outcomes include:

  • Overall survival
  • Disease-specific survival
  • Test validity
  • Change in disease status
  • Quality of life
  • Treatment-related morbidity

2

Individuals:

  • Who have B-cell acute lymphoblastic leukemia who are being monitored for residual disease following treatment

Interventions of interest are:

  • Next-generation sequencing for measurable residual disease at a threshold less than 10-4

Comparators of interest are:

  • Flow cytometry
  • Polymerase chain reaction

Relevant outcomes include:

  • Overall survival
  • Disease-specific survival
  • Test validity
  • Change in disease status
  • Quality of life
  • Treatment-related morbidity

3

Individuals:

  • Who have chronic lymphocytic leukemia who have achieved a complete response following treatment

Interventions of interest are:

  • Next-generation sequencing for measurable residual disease at a threshold of 10-4

Comparators of interest are:

  • Flow cytometry
  • Polymerase chain reaction

Relevant outcomes include:

  • Overall survival
  • Disease-specific survival
  • Test validity
  • Change in disease status
  • Quality of life
  • Treatment-related morbidity

4

Individuals:

  • Who have chronic lymphocytic leukemia who have achieved a complete response following treatment

Interventions of interest are:

  • Next-generation sequencing for measurable residual disease at a threshold less than 10-4

Comparators of interest are:

  • Flow cytometry
  • Polymerase chain reaction

Relevant outcomes include:

  • Overall survival
  • Disease-specific survival
  • Test validity
  • Change in disease status
  • Quality of life
  • Treatment-related morbidity

5

Individuals:

  • Who have multiple myeloma who have achieved a complete response following treatment

Interventions of interest are:

  • Next-generation sequencing for measurable residual disease at a threshold of 10-5

Comparators of interest are:

  • Complete response criteria
  • Next-generation flow cytometry

Relevant outcomes include:

  • Overall survival
  • Disease-specific survival
  • Test validity
  • Change in disease status
  • Quality of life
  • Treatment-related morbidity

6

Individuals:

  • Who have multiple myeloma who have achieved a complete response following treatment

Interventions of interest are:

  • Next-generation sequencing for measurable residual disease at a threshold less than 10-5

Comparators of interest are:

  • Complete response criteria
  • Next-generation flow cytometry

Relevant outcomes include:

  • Overall survival
  • Disease-specific survival
  • Test validity
  • Change in disease status
  • Quality of life
  • Treatment-related morbidity

7

Individuals:

  • Who are undergoing or have undergone treatment for diffuse large B-cell lymphoma who are being monitored for residual disease

Interventions of interest are:

  • Next-generation sequencing for measurable residual disease at a threshold of 10-4

Comparators of interest are:

  • Positron emission tomography/computed tomography
  • Flow cytometry
  • Polymerase chain reaction

Relevant outcomes include:

  • Overall survival
  • Disease-specific survival
  • Test validity
  • Change in disease status
  • Quality of life
  • Treatment-related morbidity

8

Individuals:

  • Who are undergoing or have undergone treatment for mantle cell lymphoma who are being monitored for residual disease

Interventions of interest are:

  • Next-generation sequencing for measurable residual disease at a threshold of 10-4

Comparators of interest are:

  • Positron emission tomography/computed tomography
  • Flow cytometry
  • Polymerase chain reaction

Relevant outcomes include:

  • Overall survival
  • Disease-specific survival
  • Test validity
  • Change in disease status
  • Quality of life
  • Treatment-related morbidity

Summary

Description

Measurable residual disease (MRD), also known as minimal residual disease, refers to residual clonal cells in blood or bone marrow following treatment for hematologic malignancies. MRD is typically assessed by flow cytometry (FC) or polymerase chain reaction, which can detect 1 clonal cell in 100,000 cells. It is proposed that next-generation sequencing (NGS), which can detect 1 residual clonal sequence out of 1,000,000 cells, will improve health outcomes in patients who have been treated for hematologic malignancies such as acute lymphoblastic leukemia (ALL), chronic lymphocytic leukemia (CLL), multiple myeloma (MM), diffuse large B-cell lymphoma (DLBCL), and mantle cell lymphoma (MCL).

Review of Evidence - Intro

For individuals with B-cell ALL (B-ALL) who are being monitored for residual disease following treatment who receive NGS for MRD at a threshold of 10-4, the evidence includes a retrospective comparison of data from 2 earlier trials by the Children's Oncology Group. Relevant outcomes are overall survival (OS), disease-specific survival, test validity, change in disease status, quality of life (QOL), and treatment-related morbidity. Comparison of NGS and the established standard of FC showed good concordance when the same threshold (10-4) was used for both NGS and FC. OS in pediatric patients with MRD positivity was significantly lower than in pediatric patients who were MRD negative at this threshold. The relatively small subset of patients who were discordant for FC and NGS results had outcomes that were midway between patients who were concordant as MRD positive or MRD negative for both tests. As the vast majority of patients had concordant results for NGS and FC at a threshold of 10-4, NGS can be considered an alternative to FC for monitoring MRD in patients with B-ALL. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with B-ALL who are being monitored for residual disease following treatment who receive NGS for MRD at a threshold of less than 10-4, the evidence includes retrospective analysis of prognosis from the earlier Children's Oncology Group trials as well as an analysis of tisagenlecleucel clinical trials. Relevant outcomes are OS, disease-specific survival, test validity, change in disease status, QOL, and treatment-related morbidity. NGS can be more sensitive than FC to detect the presence of residual leukemic cells, but specificity may be decreased at the more sensitive thresholds resulting in potential harm from overtreatment. Further study is needed to clarify whether MRD at levels lower than 1 in 10,000 cells represents clinically significant disease and if the more sensitive test can be used to risk-stratify patients with B-ALL. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with CLL who are being monitored for residual disease following treatment who receive NGS for MRD at a threshold of 10-4, the evidence includes analysis of samples from 2 clinical trials. Relevant outcomes are OS, disease-specific survival, test validity, change in disease status, QOL, and treatment-related morbidity. These studies evaluated the association between the level of MRD detected by NGS in bone marrow or blood and progression-free survival (PFS) in completed phase 2 and 3 trials. Both studies demonstrated an association between the level of MRD and PFS with lower risk of progression in patients who exhibit MRD negativity below 10-4 compared to patients who have detectable residual disease. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with CLL who are being monitored for residual disease following treatment who receive NGS for MRD at a threshold of less than 10-4, the evidence includes analysis of samples from 2 clinical trials. Relevant outcomes are OS, disease-specific survival, test validity, change in disease status, QOL, and treatment-related morbidity. NGS can be more sensitive than FC to detect the presence of residual leukemic cells, but it is not clear if prognosis is improved at the lower thresholds. Currently, no additional treatment is offered to eradicate low-level MRD (<10-4) after first-line treatment of CLL. Further study is needed to clarify whether MRD at levels lower than 1 in 10,000 cells represents clinically significant disease and if the more sensitive test can be used for prognosis in patients with CLL. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with MM who have achieved a complete response (CR) following treatment who receive NGS for MRD at a threshold of 10-5, the evidence includes a retrospective comparison of NGS and FC data from MM treatment trials and from a clinical series. Relevant outcomes are OS, disease-specific survival, test validity, change in disease status, QOL, and treatment-related morbidity. Concordance has been demonstrated between NGS and the established standard of FC at 10-4 as well as with next generation flow cytometry (NGF) at a threshold of 10-5. PFS in patients with MRD positivity is significantly shorter than in patients who are MRD negative at these thresholds. The relatively small subset of patients who were discordant for FC and NGS results had outcomes that were, on average, midway between patients who were concordant as MRD positive or MRD negative for both tests. Retrospective studies also indicate improved PFS when MRD is less than 10-5 compared to patients who have MRD greater than 10-5. This threshold is consistent with current guideline-based care for prognostication using either NGF or NGS. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with MM who have achieved a CR following treatment who receive NGS for MRD at a threshold of less than 10-5, the evidence includes retrospective studies on prognosis. Relevant outcomes are OS, disease-specific survival, test validity, change in disease status, QOL, and treatment-related morbidity. There is some evidence that MRD may be a prognostic marker, but there is insufficient evidence on the number of false positives in patients with CR at the more sensitive threshold provided by NGS for prognostication or to guide therapy. A chain of evidence regarding management changes based on the assessment of MRD with NGS to detect 1 malignant clonal sequence out of 1,000,000 cells cannot be completed. Direct evidence from randomized controlled trials is needed to evaluate whether patient outcomes are improved by changes in postinduction care (eg, continuing or discontinuing therapy, avoiding unnecessary adverse events) following NGS assessment of residual disease at a threshold lower than 10-5. Several trials that will test the effectiveness of NGS to guide therapy in MM are ongoing. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with DLBCL who are being monitored for residual disease following treatment who receive NGS for MRD, the evidence includes an analysis from a single-center, prospective trial. Relevant outcomes are OS, disease-specific survival, test validity, change in disease status, QOL, and treatment-related morbidity. Although both PFS and OS correlated with MRD positivity, the trial is limited by its small sample-size and inclusion of only patients eligible for HSCT from a single center. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with MCL who are being monitored for residual disease the evidence includes retrospective analyses of NGS testing during therapeutic clinical trials. Relevant outcomes are OS, disease-specific survival, test validity, change in disease status, QOL, and treatment-related morbidity. A retrospective analysis of a "research version" of an NGS test has demonstrated concordance between NGS and FC at 10-4 during induction therapy. MRD positivity as determined by either the "research version" of NGS or FC was associated with worse PFS. An exploratory analysis found improved survival in patients who were MRD negative after 2 cycles of induction; however, this is based on a small number of samples with an undefined threshold for NGS testing. Overall, the literature is limited, and guidelines for NGS testing to detect MRD in patients with MCL are lacking. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Additional Information

This Evidence Opinion was reviewed by the Blue Cross Blue Shield Association Medical Advisory Panel on October 3, 2019.

Objective

The objective of this evidence review is to determine whether next-generation sequencing for measurable residual disease improves the net health outcome in individuals with B-cell acute lymphoblastic leukemia, chronic lymphocytic leukemia, multiple myeloma, diffuse large B-cell lymphoma, or mantle cell lymphoma tested for measurable residual disease.

Policy Statements

Next-generation sequencing (eg clonoSEQ) to detect measurable residual disease (MRD) at a threshold of 10-4 as an alternative test in individuals with acute lymphoblastic leukemia may be considered medically necessary.

Next-generation sequencing (eg clonoSEQ) to detect MRD at a threshold of less than 10-4 in individuals with acute lymphoblastic leukemia is considered investigational.

Next-generation sequencing (eg clonoSEQ) to detect MRD at a threshold of 10-4 as an alternative test in individuals with chronic lymphocytic leukemia may be considered medically necessary.

Next-generation sequencing (eg clonoSEQ) to detect MRD at a threshold of less than 10-4 in individuals with chronic lymphocytic leukemia is considered investigational.

Next-generation sequencing (eg clonoSEQ) to detect MRD at a threshold of 10-5 as an alternative test in individuals with multiple myeloma may be considered medically necessary.

Next-generation sequencing (eg clonoSEQ) to detect MRD at a threshold of less than 10-5 in individuals with multiple myeloma is considered investigational.

Next-generation sequencing (eg clonoSEQ) to detect MRD at a threshold of 10-4 in individuals with diffuse large B-cell lymphoma is considered investigational.

Next-generation sequencing (eg clonoSEQ) to detect MRD at a threshold of 10-4 in individuals with mantle cell lymphoma is considered investigational.

Next-generation sequencing to detect MRD is considered investigational in all other situations.

Policy Guidelines

See Codes table for details.

Benefit Application

BlueCard/National Account Issues

State or federal mandates (eg, Federal Employee Program) may dictate that certain U.S. Food and Drug Administration approved devices, drugs, or biologics may not be considered investigational, and thus these devices may be assessed only by their medical necessity.

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered.  Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage. 

Background

Disease

There are 3 main types of hematologic malignancies: lymphomas, leukemias, and myelomas. Lymphoma begins in lymph cells of the immune system, which originate in the bone marrow and collect in lymph nodes and other tissues. Leukemia is caused by the overproduction of abnormal white blood cells in the bone marrow, which leads to a decrease in the production of red blood cells and plasma cells. The most common forms of leukemia are acute lymphoblastic leukemia, chronic lymphocytic leukemia, acute myeloid leukemia, and chronic myeloid leukemia. Multiple myeloma (MM), also called plasma myeloma, is a malignancy of plasma cells in the bone marrow. The present evidence review will address B-cell acute lymphoblastic leukemia, chronic lymphocytic leukemia, multiple myeloma, diffuse large B-cell lymphoma, and mantle cell lymphoma. As B-Cell acute lymphoblastic leukemia and B-Cell lymphoblastic lymphoma are generally considered clinically indistinct, reference to B-Cell acute lymphoblastic leukemia is intended to encompass both entities.

Treatment

Treatment depends on the type of malignancy and may include surgery, radiotherapy, chemotherapy, targeted therapy, plasmapheresis, biologic therapy, or hematopoietic cell transplant. Treatment of acute leukemias can lead to complete remission. Multiple myeloma and the chronic leukemias are treatable but generally incurable. Outcomes of lymphoma vary by subtype, and some forms are curable.

Measurable Residual Disease

Relapse is believed to be due to residual clonal cells that remain following "complete response” after induction therapy but are below the limits of detection using conventional morphologic assessment. Residual clonal cells that can be detected in the bone marrow or blood are referred to as measurable residual disease (MRD), also known as minimal residual disease. MRD assessment is typically performed by flow cytometry or polymerase chain reaction (PCR) with primers for common variants. Flow cytometry or next generation flow cytometry evaluates blasts based on the expression of characteristic antigens, while PCR assesses specific chimeric fusion gene transcripts, gene variants, and overexpressed genes. PCR is sensitive for specific targets, but clonal evolution may occur between diagnosis, treatment, remission, and relapse that can affect the detection of MRD. Next-generation sequencing (NGS) has 10- to 100-fold greater sensitivity for detecting clonal cells, depending on the amount of DNA in the sample (see Table 1) and does not require patient-specific primers. For both PCR and NGS a baseline sample at the time of high disease load is needed to identify tumor-specific sequences. MRD with NGS is frequently used as a surrogate measure of treatment efficacy in drug development.

It is proposed that by using a highly sensitive and sequential MRD surveillance strategy, one could expect better outcomes when therapy is guided by molecular markers rather than hematologic relapse. However, some patients may have hematologic relapse despite no MRD, while others do not relapse despite residual mutation-bearing cells. Age-related clonal hematopoiesis, characterized by somatic variants in leukemia-associated genes with no associated hematologic disease, further complicates the assessment of MRD. One available test ( clonoSEQ) uses both PCR and NGS to detect clonal DNA in blood and bone marrow. ClonoSEQ Clonality (ID) PCR assessment is performed when there is a high disease load (eg, initial diagnosis or relapse) to identify dominant or “trackable” sequences associated with the malignant clone. NGS is then used to monitor the presence and level of the associated sequences in follow-up samples. As shown in Table 1, NGS can detect clonal cells with greater sensitivity than either flow cytometry or PCR, although next-generation flow techniques have reached a detection limit of 1 in 10-5 cells, which is equal to PCR and approaches the limit of detection of NGS (see Table 1).

Table 1. Sensitivity of Methods for Detecting Measurable Residual Disease

Technique
Sensitivity
Detection limit of blasts per 100,000 Nucleated Cells
Microscopy (complete response)
 
50,000
Multiparameter flow cytometry
10-4
10
Next-generation flow cytometry
10-5
1.0
Polymerase chain reaction
10-5
1.0
Quantitative next-generation sequencing
10-5
1.0
Next-generation sequencing
10-6
0.1

 

Regulatory Status

The clonoSEQ® Minimal Residual Disease Test is offered by Adaptive Biotechnologies. clonoSEQ® was previously marketed as clonoSIGHT™ (Sequenta), which was acquired by Adaptive Biotechnologies in 2015. clonoSIGHT™ was a commercialized version of the LymphoSIGHT platform by Sequenta for clinical use in MRD detection in lymphoid cancers. In September 2018, clonoSEQ received marketing clearance from the U.S. Food and Drug Administration (FDA) through the de novo classification process to detect MRD in patients with acute lymphoblastic leukemia or multiple myelomaIn 2020, clonoSEQ received marketing clearance from the FDA to detect MRD in patients with chronic lymphocytic leukemia.

Rationale

This evidence review was created in October 2018 and has been updated regularly with searches of the PubMed database. The most recent literature update was performed through October 18, 2023.

Evidence reviews assess whether a medical test is clinically useful. A useful test provides information to make a clinical management decision that improves the net health outcome. That is, the balance of benefits and harms is better when the test is used to manage the condition than when another test or no test is used to manage the condition.

The first step in assessing a medical test is to formulate the clinical context and purpose of the test. The test must be technically reliable, clinically valid, and clinically useful for that purpose. Evidence reviews assess the evidence on whether a test is clinically valid and clinically useful. Technical reliability is outside the scope of these reviews, and credible information on technical reliability is available from other sources.

Promotion of greater diversity and inclusion in clinical research of historically marginalized groups (e.g., People of Color [African-American, Asian, Black, Latino and Native American]; LGBTQIA (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual); Women; and People with Disabilities [Physical and Invisible]) allows policy populations to be more reflective of and findings more applicable to our diverse members. While we also strive to use inclusive language related to these groups in our policies, use of gender-specific nouns (e.g., women, men, sisters, etc.) will continue when reflective of language used in publications describing study populations.”

Population Reference No. 1 & 2

Next-Generation Sequencing to Detect Measurable Residual Disease in B-Cell Acute Lymphoblastic Leukemia

Clinical Context and Test Purpose

Acute lymphoblastic leukemia (ALL) is the most common cancer diagnosed in children; it represents nearly 25% of cancers in children younger than 15 years and 20% of acute leukemias in adults. Remission of disease is now typically achieved with pediatric chemotherapy regimens in 98% of children with ALL, with up to 85% long-term survival rates. The prognosis after the first relapse is related to the length of the original remission. For example, the leukemia-free survival rate is 40% to 50% for children whose first remission was longer than 3 years compared with 10% to 15% for those who relapse less than 3 years after treatment. Between 60% and 80% of adults with ALL can be expected to achieve a complete response (CR) after induction chemotherapy; however, only 35% to 40% can be expected to survive 2 years. “Poor prognosis” genetic abnormalities such as the Philadelphia chromosome (translocation of chromosomes 9 and 22) are seen in 25% to 30% of adult ALL but infrequently in childhood ALL. Other adverse prognostic factors in adult ALL include age greater than 35 years, poor performance status, male sex, and leukocytosis count of greater than 30,000/μL (B-cell lineage) or greater than 100,000/μL (T-cell lineage) at presentation.

Induction therapy aims to reduce the leukemic cell population below the cytological detection limit (about 1010 cells or 1 malignant cell for every 20 to 100 normal cells), but it is believed that remaining leukemic cells that are below the level of clinical and conventional morphologic detection lead to relapse if no further treatment were given. Consolidation and intensification therapy is intended to eradicate this residual disease. The type of post-remission therapy (chemotherapy or autologous or allogeneic hematopoietic cell transplantation [HCT]) depends on the expected rate of relapse and patient characteristics such as age and comorbidities. Bone marrow is examined every 3 to 6 months for a minimum of 2 years to determine clinical relapse. If a patient is in CR for 7 to 8 years they are considered cured. Most children and up to one-half of adults will have prolonged disease-free survival, but up to 20 percent of adults will have a resistant disease, and a majority of adults and some children will eventually relapse and die of leukemia.

Measurable, or minimal, residual disease (MRD) is used to assess the subclinical residual disease. Patients with detectable MRD have an increased risk of relapse, but the absolute risk varies depending on the timing of MRD evaluation, the sensitivity of the method used, and baseline characteristics of the patient and tumor. In addition, not all patients with MRD positivity will relapse clinically because some cells with abnormal markers may lack the ability to create disease. Other patients will relapse despite no detectable disease as a result of malignant progenitor cells that lack the initially identified markers. MRD is most commonly measured with polymerase chain reaction (PCR) and flow cytometry (FC).

MRD assays are routinely used in the clinical care of children and increasingly in adults with ALL, although the choice of tests may depend on how the results will impact patient care. FC may be preferred if there are plans to escalate care because results are rapidly available and the likelihood of relapse with this less sensitive test is high. PCR may be preferred to identify patients with a low risk of relapse when a reduction in treatment intensity is being considered. Some clinicians use more than 1 technique to minimize false-negative results, or at multiple time points to assess disease trajectory, and ongoing trials are evaluating whether children who demonstrate a rapid clearance of tumor cells during induction therapy may be candidates for less intensive therapy. In adults who have a high rate of relapse, MRD is being studied to identify patients who require intensified treatment.

Next-generation sequencing (NGS) is a newer technique that is commercially available (eg, clonoSEQ). NGS is more sensitive than other methods and can detect up to 1 leukemic cell in 1,000,000 cells if there is sufficient DNA in the sample (see Table 1), but other performance characteristics are not well established.

The main use of measurement of MRD with NGS is to risk-stratify and inform treatment management.1,

The following PICO was used to select literature to inform this review.

Populations

The relevant population of interest is patients who have received induction therapy for B-ALL. Patients who achieve a clinical CR following induction therapy would be assessed for MRD to determine whether additional therapy might be recommended prior to HCT. Patients who have relapsed or refractory diseases would be assessed for the Philadelphia chromosome and if negative may undergo assessment for MRD.

Interventions

The test being considered is MRD assessment by NGS (eg, clonoSEQ). This test is proposed as an adjunct to clinical assessment and an alternative to FC and PCR. NGS utilizes locus-specific primers for immunoglobulin gene rearrangements in IGH-VDJH, IGHDJH, or IGK. This technique does not require the use of patient-specific primers, but baseline bone marrow samples are required in order to identify the dominant clonotype. MRD positivity or negativity is reported at all thresholds (eg positive at 10-4 but negative at 10-5). The sensitivity of this technique can reach up to 10−6 depending on the quantity of DNA available from the bone marrow sample. This evidence review will evaluate outcomes for NGS at different thresholds.

Comparators

The following tests are currently being used to inform treatment decisions for those with B-ALL: FC (sensitivity of 10-4) and PCR (sensitivity of 10-5). Meta-analysis of 39 studies (13637 patients) that evaluated survival outcomes found that MRD negativity with either FC or PCR was associated with a better long-term outcome.2, Ten-year event-free survival with MRD negativity was 77% in children and 64% in adults compared to 32% and 21%, respectively, in patients who were MRD positive. For reference, the event-free survival hazard ratio (HR) for MRD negativity/positivity with FC or PCR was 0.23 (95% Bayesian credible interval, 0.18-0.28) for pediatric patients and 0.28 (95% Bayesian credible interval, 0.24-0.33) for adults.

Outcomes

The general outcomes of interest are remission and relapse in the short-term and survival at a longer follow-up.

Beneficial outcomes of a true-positive test result (presence of clinically significant residual disease) would be the administration of an effective treatment leading to a reduction in relapse and improvement in overall survival (OS). The beneficial outcome of a true-negative test (absence of clinically significant disease) is the avoidance of unnecessary treatment and reduction of adverse events.

Harmful outcomes of a false-positive test are an unnecessary treatment for ALL resulting in treatment-related harms. Harmful outcomes of a false-negative test are a reduction in necessary treatment or delayed treatment, with a potential impact in progression-free survival (PFS) and OS.

Direct harms of the test are repeated bone marrow biopsy, although bone marrow samples are also needed for FC. Harms of repeated bone marrow biopsy may include tenderness or pain, bleeding or bruising, and swelling.

Relapse of B-ALL may be measured in 2 years. Changes in survival from B-ALL would be observable at a minimum of 5 years.

Study Selection Criteria

For the evaluation of the clinical validity of the clonoSEQ test, studies that met the following eligibility criteria were considered:

OR, comparative trials that evaluated health outcomes when therapy was guided by NGS assessment of MRD.

Clinically Valid

A test must detect the presence or absence of a condition, the risk of developing a condition in the future, or treatment response (beneficial or adverse).

Review of Evidence

Tables 2, 3, and 4 describe studies that have evaluated prognosis based on MRD levels detected by FC and NGS. Overall, higher levels of MRD are associated with a worse prognosis. In a study by Wood et al (2018), there was high concordance between FC and NGS at a threshold of 10-4 in pediatric B-ALL (data are shown graphically in the publication).3, A subset of these results was submitted to the U.S. Food and Drug Administration in support of the de novo clearance. OS in pediatric patients with MRD positivity was significantly lower than in pediatric patients who were MRD negative at this threshold. At an MRD threshold of 10-4, NGS identified 55 patients as MRD-positive who were MRD-negative by FC, while 17 patients were MRD-positive by FC but MRD-negative by NGS (see Table 3). Patients who were FC negative/NGS positive had outcomes that were midway between patients who were concordant as MRD positive or MRD negative for both tests.

Notably, higher levels of sensitivity were associated with a decrease in clinical specificity, with a larger fraction of MRD-positive patients with relatively good outcome (data not shown in the publication). With MRD negativity set at a threshold of 10-6, OS was 100% in the standard-risk group and 95.1% in the high-risk group (see Table 4), but at this threshold, there was not a statistically significant difference in OS between the MRD positive and MRD negative patients for either group. The maximal HR for NGS was obtained at 10-4, which is the sensitivity of FC. A smaller study by Pulsipher et al (2015) compared NGS at 10-6 with FC assessed before and after HCT in pediatric patients with ALL.4, NGS was more successful at predicting the relapse probability and OS compared to FC. The major limitations of these studies are shown in Tables 5 and 6. A limitation in Wood et al (2018) is that samples were only available at the end of induction, so the results only apply to the end of induction. In addition, the data on sensitivity and specificity at other thresholds were not reported, although the study did assess the threshold with the greatest HR, which was calculated to be 10-4 (the same as FC). Both studies were conducted in pediatric ALL patients, and results may not apply fully to adults or be applicable to other periods in the treatment course.

In an analysis of samples from 2 multicenter studies, Pulsipher et al (2022) compared FC at a threshold of 10-4 with NGS at thresholds of 10-4, 10-5, 10-6, and any detectable level (approximately 10-7) in pediatric and young adult patients with B-ALL who received tisagenlecleucel.5, In 95 patients with both NGS and FC results, 18% of samples were MRD-positive with FC compared with 22%, 29%, 33%, and 41% with NGS at cutoff values of 10-4, 10-5, 10-6, and any detectable level, respectively. No samples were positive by FC and negative by NGS.

Liang et al (2023) reported results of a study of the prognostic performance of the clonoSEQ assay in 111 adult participants with B-cell or T-cell ALL who underwent allogeneic HCT at Stanford University or Oregon Health & Science University between 2014 and 2021.6, Participants were followed for leukemia relapse and/or death for up to 2 years after HCT. Relapse was defined as morphologic or clinical. The MRD samples came from either peripheral blood or bone marrow. The median age of the patients was 44 years (range, 19 to 70 years), 62 (56%) were male, and 95 (86%) had B-cell ALL.

Table 2. Characteristics of Prognostic Studies Assessing NGS for MRD in B-cell ALL

Study Study Population Designa Reference Standard Threshold for PIT FU Test Version
Liang et al (2023)6, Blood and bone marrow samples from adults with B-cell (86%) or T-cell ALL undergoing HCT Retrospective from banked samples; assessed by NGS Relapse Presence of a detectable IgH clonotype in B-cell ALL or the presence of a detectable TCRβ or TCRγ clonotype in T-cell ALL.

Stratified as undetectable (0), low (<10–4), high (≥10–4 to ≤10–3), or very high (>10–3)
Up to 2 years clonoSEQ
Pulsipher et al (2022)5, Blood and bone marrow samples from 143 patients in tisagenlecleucel trials Retrospective from banked samples with comparison of FC and NGS Relapse FC at 10-4; NGS at 10-4 or less 38.4 mo clonoSEQ
Wood et al (2018)3, 619 paired bone marrow samples from pediatric B-ALL patients before and after induction chemotherapy in COG trials Retrospective from banked samples with comparison of FC and NGS Event-free survival and overall survival FC at 10-4; NGS at 10-4 and 10-5 5 y ImmunoSEQ
Pulsipher et al (2015)4, Before (n=41) and after HCT (n=57) marrow samples from pediatric ALL patients in COG trials Retrospective from banked samples with comparison of FC and NGS Time to relapse following HCT FC at 10-4; NGS at 10-6   ImmunoSEQ
ALL: acute lymphoblastic leukemia; COG: Children's Oncology Group; FC: flow cytometry; FU: follow-up; HCT: hematopoietic cell transplantation; MRD: measurable residual disease; NGS: next-generation sequencing; PIT: positive index test.
Table 3. Concordance Between FC and NGS at a Threshold of 10-4 from Wood et al (2018)3,
    Flow Cytometry  
  + - Total
NGS + 87 55 142
- 17 409 426
  Total 104 464 568
FC: flow cytometry; NGS: next-generation sequencing.
Table 4. Results of Prognostic Studies Assessing NGS for MRD in B-cell ALL
Study N MRD Threshold Results
      Relapse, % 5-Year EFS, % (SD) OS, % (SD) Hazard Ratio
Liang et al (2023)6, 111 (95 B-cell ALL) MRD before HCT:
Undetectable (n=82)
Low (<10–4; n=24),
High (>10–4 to ≤10–3; n=11)
Very high (>10–3; n=5)
Undetectable, <10%
Low, ~35%
High, ~30%
Very high, ~55%
    Undetectable, Reference
Low, HR=3.6 (1.4 to 9.2)
High, HR=2.9 (0.8 to 11.2)
Very high, HR=7.0 (2.1 to 22.9)
Pulsipher et al (2022)5, 143 As low as "any detectable level" (roughly corresponding to 10-7) Relapse before 12 months occurred without MRD detection in 50% of patients by FC, 31% by NGS at 10-6, and 0% of those with NGS below the 10-6 level      
Wood et al (2018)3, 282 Standard Risk EOI NGS negative <10-6 (n=56)   98.1 (2) 100 (0) Maximal at 10-4
  297 High Risk EOI NGS negative <10-6 (n=89)   92.7 (4) 95.1 (3)  
      Relapse Probability at 2 Years, %      
Pulsipher et al (2015)4, 41 Pre-HCT FC negative 16      
    Pre-HCT NGS negative 0      
    Pre-HCT FC positive 46      
    Pre-HCT NGS positive 53      
EFS: event-free survival; EOI: end of induction; FC: flow cytometry; HCT: hematopoietic cell transplantation; MRD: measurable residual disease; NGS: next-generation sequencing; OS: overall survival; PPV: positive predictive value; SD: standard deviation; TTP: time to progression.

Limitations in study relevance, and study design and conduct are shown in Tables 5 and 6.

Table 5. Study Relevance Limitations
Study Populationa Interventionb Comparatorc Outcomesd Duration of Follow-Upe
Liang et al (2023)6, 4. Included participants with B-cell or T-cell ALL   2. No comparator   1. Limited follow-up duration
Pulsipher et al (2022)5, 4. Results specific to patients treated withtisagenlecleucel       1. Limited follow-up duration
Wood et al (2018)3, 4. Results are specific to pediatric B-ALL. Stored samples were available only at the end of induction. 3. Used ImmunoSEQ rather than clonoSEQ      
Pulsipher et al (2015)4, 4. Results are specific to pediatric ALL. 3. Used ImmunoSEQ rather than clonoSEQ      
The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
ALL: acute lymphoblastic leukemia.
a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.
b Intervention key: 1. Classification thresholds not defined; 2. Version used unclear; 3. Not intervention of interest.
c Comparator key: 1. Classification thresholds not defined; 2. Not compared to credible reference standard; 3. Not compared to other tests in use for same purpose.
d Outcomes key: 1. Study does not directly assess a key health outcome; 2. Evidence chain or decision model not explicated; 3. Key clinical validity outcomes not reported (sensitivity, specificity, and predictive values); 4. Reclassification of diagnostic or risk categories not reported; 5. Adverse events of the test not described (excluding minor discomforts and inconvenience of venipuncture or noninvasive tests).
e Follow-Up key: 1. Follow-up duration not sufficient with respect to natural history of disease (true-positives, true-negatives, false-positives, false-negatives cannot be determined).
Table 6. Study Design and Conduct Limitations
Study Selectiona Blindingb Delivery of Testc Selective Reportingd Data Completenesse Statisticalf
Liang et al (2023)6, 2. Selection based on availability of samples from prior studies 1. Blinding was not described        
Pulsipher et al (2022)5, 2. Selection based on availability of samples from prior studies 1. Blinding was not described 2. FC analysis was part of the original trials; NGS was performed on frozen samples post hoc      
Wood et al (2018)3, 2. Selection based on availability of tissue samples from prior studies     2. NGS at 10-4 was not prespecified. The lack of specificity with other thresholds was mentioned.    
Pulsipher et al (2015)4, 2. Selection based on availability of tissue samples from prior studies 1. Blinding was not described        
NGS: next-generation sequencing.
The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
a Selection key: 1. Selection not described; 2. Selection not random or consecutive (ie, convenience).
b Blinding key: 1. Not blinded to results of reference or other comparator tests.
c Test Delivery key: 1. Timing of delivery of index or reference test not described; 2. Timing of index and comparator tests not same; 3. Procedure for interpreting tests not described; 4. Expertise of evaluators not described.
d Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.
e Data Completeness key: 1. Inadequate description of indeterminate and missing samples; 2. High number of samples excluded; 3. High loss to follow-up or missing data.
f Statistical key: 1. Confidence intervals and/or p values not reported; 2. Comparison with other tests not reported.

Clinically Useful

A test is clinically useful if the use of the results informs management decisions that improve the net health outcome of care. The net health outcome can be improved if patients receive correct therapy, or more effective therapy, or avoid unnecessary therapy, or avoid unnecessary testing.

Direct Evidence

Direct evidence of clinical utility is provided by studies that have compared health outcomes for patients managed with and without the test. Because these are intervention studies, the preferred evidence would be from randomized controlled trials (RCTs). No trials were identified that compared outcomes when treatment was guided by NGS.

Chain of Evidence

Indirect evidence on clinical utility rests on clinical validity. If the evidence is insufficient to demonstrate test performance, no inferences can be made about clinical utility.

There is sufficient evidence on test performance when NGS results are reported at 10-4, which is comparable to other established methods of measuring MRD such as FC. However, performance characteristics at lower thresholds are uncertain, and there is some evidence that false-positives may be increased with a more sensitive test. Therefore, a chain of evidence cannot be constructed regarding the clinical utility of measurement of MRD at less than 10-4 in patients with ALL.

Section Summary: Next Generation Sequencing to Detect Measurable Residual Disease in Acute Lymphoblastic Leukemia

Evidence on the clinical validity of NGS to risk-stratify patients includes 2 retrospective studies in pediatric patients with ALL who had participated in earlier trials by the Children's Oncology Group and 2 retrospective studies in adults. The largest study was conducted in stored samples from before and after induction therapy, and MRD negativity was one of several factors that were used to risk-stratify patients. Comparison with FC showed comparable results when the same threshold (10-4) was used for both NGS and FC, and OS in pediatric patients with MRD positivity was significantly lower than in pediatric patients who were MRD negative. However, NGS at the limit of detection (10-6 or 1 leukemic cell in 1,000,000 normal cells) was found to have lower specificity. Thus, in 1 study of over 600 pediatric patients with B-ALL undergoing induction, risk stratification based on NGS and FC were comparable at a threshold of 10-4, but NGS had more false-positives with lower thresholds. In another retrospective study in pediatric and young adult patients who were enrolled in tisagenlecleucel clinical trials, NGS was only of prognostic importance at levels below the threshold of 10-6.

Guidelines state that MRD quantification is an essential component of patient evaluation. Evidence is sufficient to support the clinical utility of using NGS to measure MRD when patient management is based on test results at a sensitivity of 10-4. Evidence is insufficient to evaluate benefits and harms when treatment decisions are made based on NGS results at thresholds lower than 10-4. Few studies have been performed to assess whether the identification of 1 in 1,000,000 cells identifies clinically significant residual disease, and false-positives may be increased resulting in harm from overtreatment. Further study is needed to clarify which threshold of NGS should be considered when risk stratifying patients and whether treatment decisions based on the more sensitive assay improves the net health outcome.

For individuals with B-cell ALL (B-ALL) who are being monitored for residual disease following treatment who receive NGS for MRD at a threshold of 10-4, the evidence includes a retrospective comparison of data from 2 earlier trials by the Children's Oncology Group. Relevant outcomes are overall survival (OS), disease-specific survival, test validity, change in disease status, quality of life (QOL), and treatment-related morbidity. Comparison of NGS and the established standard of FC showed good concordance when the same threshold (10-4) was used for both NGS and FC. OS in pediatric patients with MRD positivity was significantly lower than in pediatric patients who were MRD negative at this threshold. The relatively small subset of patients who were discordant for FC and NGS results had outcomes that were midway between patients who were concordant as MRD positive or MRD negative for both tests. As the vast majority of patients had concordant results for NGS and FC at a threshold of 10-4, NGS can be considered an alternative to FC for monitoring MRD in patients with B-ALL. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

Population

Reference No. 1

Policy Statement

 [X] Medically Necesary

 [ ] Investigacional 

For individuals with B-ALL who are being monitored for residual disease following treatment who receive NGS for MRD at a threshold of less than 10-4, the evidence includes retrospective analysis of prognosis from the earlier Children's Oncology Group trials as well as an analysis of tisagenlecleucel clinical trials. Relevant outcomes are OS, disease-specific survival, test validity, change in disease status, QOL, and treatment-related morbidity. NGS can be more sensitive than FC to detect the presence of residual leukemic cells, but specificity may be decreased at the more sensitive thresholds resulting in potential harm from overtreatment. Further study is needed to clarify whether MRD at levels lower than 1 in 10,000 cells represents clinically significant disease and if the more sensitive test can be used to risk-stratify patients with B-ALL. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Population

Reference No. 2

Policy Statement

 [  ] Medically Necesary

 [X] Investigacional 

Population Reference No. 3 & 4

Next-Generation Sequencing to Detect Measurable Residual Disease in Chronic Lymphocytic Leukemia

Clinical Context and Test Purpose

Chronic lymphocytic leukemia (CLL) is the most common leukemia in Western countries, representing approximately 25% to 30% of all leukemias. CLL is characterized by progressive accumulation of functionally incompetent monoclonal B lymphocytes. It occurs primarily in older adults, but occurrence in younger adults is not unusual. The incidence of CLL increases with age with a median age at diagnosis of 70 years. Malignant cells in CLL and the non-Hodgkin lymphoma small lymphocytic lymphoma have identical pathologic and immunophenotypic features. The term CLL is used when the disease manifests primarily in the blood, whereas the term small lymphocytic lymphoma is used for primarily nodal manifestation.

Not all patients with CLL will require treatment at the time of diagnosis. Median survival for patients with asymptomatic CLL is 10 years, and some patients with early stage CLL may be asymptomatic without treatment for decades. Importantly, randomized trials evaluating immediate versus delayed treatment strategies have found no improvement in long-term survival with early treatment, survival in some patients will not be different from the normal population, and with the exception of HCT, there is currently no cure for CLL. Therefore, the standard of care for patients with early stage asymptomatic CLL is observation rather than immediate treatment.

Treatment is indicated for patients with disease-related complications, termed "active disease" by the International Workshop on Chronic Lymphocytic Leukemia.6, Criteria for active disease include 1 or more of the following: progressive marrow failure, splenomegaly, lymphadenopathy, progressive lymphocytosis, autoimmune anemia and/or thrombocytopenia, extranodal involvement (eg, skin, kidney, lung, spine), and constitutional symptoms such as weight loss, fatigue, fever, and night sweats. The goal of therapy is to ameliorate symptoms and improve PFS and OS. The choice of therapy is based on patient and tumor characteristics and goals of therapy. Most patients will have an initial complete or partial response to treatment but will eventually relapse. Relapse may be asymptomatic but is monitored closely for progression to active disease.

Test Purpose

The main use of measurement of MRD with NGS in patients with CLL is to predict treatment efficacy.

The analytic framework for the use of MRD for CLL, based on guidelines from the National Comprehensive Cancer Network7,, is shown in Figure 1.

Figure 1. Analytic Framework for the use of MRD to Inform Treatment Management in CLL.

The following PICO was used to select literature to inform this review.

Populations

The relevant population of interest is patients who are undergoing or have undergone treatment for CLL.

Interventions

The test being considered is MRD assessment by NGS (eg, clonoSEQ). NGS utilizes locus-specific primers for immunoglobulin gene rearrangements, which are rearranged in CLL patients. Baseline blood or bone marrow samples at the time of high disease load are required in order to identify the dominant clonotype.

Comparators

MRD detection by NGS would be an adjunct to clinical measures of progression and an alternative to FC or next generation flow cytometry (NGF), which has a sensitivity of 10-5.

Outcomes

The general outcomes of interest are a clinical progression in the short term and survival at a longer follow-up.

Beneficial outcomes of a true-positive test result (detection of clinically significant disease) would be intensification or continuation of an effective treatment leading to longer PFS. The beneficial outcome of a true-negative test (absence of clinically significant residual disease) is the avoidance of unnecessary treatment and reduction of adverse events.

Harmful outcomes of a false-positive test include an increase or continuation of unnecessary treatment resulting in treatment-related harm. Harmful outcomes of a false-negative test include a reduction in necessary treatment or delayed treatment, with a potential impact on disease progression.

Direct harms of the test are repeated bone marrow biopsy. Harms of repeated bone marrow biopsy may include tenderness or pain, bleeding or bruising, and swelling.

Utility of MRD to guide treatment of CLL may be measured in months for progression of the disease, with survival measured in years.

Study Selection Criteria

For the evaluation of the clinical validity of the clonoSEQ test, studies that met the following eligibility criteria were considered:

OR, comparative trials that evaluated health outcomes when therapy was guided by NGS assessment of MRD.

Clinically Valid

A test must detect the presence or absence of a condition, the risk of developing a condition in the future, or treatment response (beneficial or adverse).

Review of Evidence

Study characteristics and results are described in Tables 7 and 8. Study limitations are described in Tables 9 and 10.

Material submitted for U.S. Food and Drug Administration (FDA) approval included data analyzed from 2 studies that assessed MRD with clonoSeq using available blood samples from 2 clinical trials (NCT02242942 and NCT00759798).9, The primary endpoint of the first study was to evaluate whether MRD at a threshold of 10-5 at 3 months after treatment could predict PFS. Secondary objectives were to assess different cutoff values and repeated measurements. Patients with MRD greater than 10-5 had a 6.64-fold higher event risk compared to MRD negative patients (95% CI, 3.65-12.1). The primary distinction was at a cutoff of 10-4, where only 16.5% of patients with MRD in blood greater than 10-4 were progression free at 4 yr follow-up, compared to 44%, 49%, and 47% with MRD less than 10-6, 10-5, and 10-4, respectively.

The second study was published by Thompson et al (2019), who analyzed MRD with NGS in stored samples of bone marrow (n=57), blood (n=29) and plasma (n=32) from 62 patients who had previously tested negative for MRD by FC (N=63) in a phase 2 clinical trial.10, MRD rates by NGS varied according to sample type with fewer patients with undetectable MRD in bone marrow (25%) than blood (55%) or plasma (75%). MRD at the end of treatment was predictive of PFS. Patients with undetectable MRD did not progress by the end of the study (mean 82 months, range 28 to 112 months) compared with PFS of 67 months (bone marrow) or 74 months (blood). The percent of patients who were progression free with MRD less than 10-6, 10-5, and 10-4 was 85%, 75%, and 67.5%, respectively. The authors note that "At this time, no additional treatment is offered to eradicate low-level MRD (<10-4) after first-line treatment of CLL, given the generally favorable prognosis for such patients."

Munir et al (2023) reported results of the prognostic performance of clonoSEQ in participants from the GLOW study11,. GLOW (NCT03462719; n=211) was a phase III trial comparing fixed-duration ibrutinib+venetoclax to chlorambucil+obinutuzumab in participants with previously untreated CLL who were older and/or had comorbidities. MRD was assessed by clonoSEQ from samples collected every 3-4 months from peripheral blood and at 9 and 18 months from bone marrow. Detectable MRD defined as having ≥1 CLL cell per 10,000 leukocytes. Median follow-up was 34 months. PFS at 12 months after the end of treatment with ibrutinib+venetoclax was high regardless of MRD status at the end of treatment: 96% versus 93% in patients with undetectable MRD versus detectable MRD.

Table 7. Characteristics of Prognostic Studies Assessing NGS for MRD in CLL

Study Study Population Designa Reference Standard Threshold for PIT FU (range) Test Version
clonoSEQ Technical Summary Patients treated for CLL with blood samples at 3 mo after treatment (n=337) Analysis of prospectively collected blood samples from a phase 3 trial (NCT02242942) PFS NGS at 10-6 ,10-5 ,10-4 in blood 4 yr clonoSEQ
Thompson et al (2019)10, Patients with CLL treated with up to 6 courses of FCR and MRD negative by FC (n=62) Analysis of prospectively collected samples from a phase 2 trial (NCT00759798) PFS NGS at 10-6 ,10-5 ,10-4 in blood, plasma, or bone marrow 82 mo (28-112) clonoSEQ
Munir et al (2023)11, Patients with CLL treated with ibrutinib+venetoclax Analysis of prospectively collected samples from the phase 3 GLOW trial (NCT03462719) PFS NGS at 10-4 1 yr clonoSEQ
CLL: chronic lymphocytic leukemia; FC: flow cytometry; FCR: fludarabine, cyclophosphamide, and rituximab; FU: follow-up; MRD: measurable residual disease; NGS: next-generation sequencing; PIT: positive index test; PFS: progression-free survival.
Table 8. Results of Prognostic Studies Assessing NGS for MRD in CLL
Study N Tissue Source Progression Free at End of Study n/N (%)
      EOT MRD <10-6 EOT MRD >10-6 EOT MRD <10-5 EOT MRD >10-5 EOT MRD <10-4 EOT MRD >10-4
clonoSEQ Technical Summary     33/75 (44.0%)   50/106 (47.2%)   24/49 (49.0%) 17/103 (16.5%)
Thompson et al (2019)10, 53 Bone Marrow 11/13 (84.6%) 21/40 (52.5%) 18/24 (75.0%) 14/29 (48.3%) 27/40 (67.5%) 5/13 (38.4%)
  29 Blood 7/8 (87.5%) 8/13 (61.5%)        
Munir et al (2023)11, 211 (106 ibrutinib+venetoclax) Bone marrow         ibrutinib+venetoclax,
96%

chlorambucil+obinutuzumab,
83%
ibrutinib+venetoclax,,
,93%

chlorambucil+obinutuzumab,
59%
 EOT: end of treatment; MRD: measurable residual disease; NGS: next-generation sequencing; PFS: progression free survival

Limitations in study relevance, and study design and conduct are shown in Tables 9 and 10.

Table 9. Study Relevance Limitations
Study Populationa Interventionb Comparatorc Outcomesd Duration of Follow-Upe
clonoSEQ Technical Summary     3. Did not compare results to FC    
Thompson et al (2019)10,         1. Mean FU was 82 months (range of 28 to 118 mo) which is insufficient to determine PFS in CLL
Munir et al (2023)11,     3. Did not compare results to FC   1. Follow-up of 1 year
The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
CLL: chronic lymphocytic leukemia; FC. flow cytom etry; FU: follow-up; PFS: progression-free survival.
a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.
b Intervention key: 1. Classification thresholds not defined; 2. Version used unclear; 3. Not intervention of interest.
c Comparator key: 1. Classification thresholds not defined; 2. Not compared to credible reference standard; 3. Not compared to other tests in use for same purpose.
d Outcomes key: 1. Study does not directly assess a key health outcome; 2. Evidence chain or decision model not explicated; 3. Key clinical validity outcomes not reported (sensitivity, specificity, and predictive values); 4. Reclassification of diagnostic or risk categories not reported; 5. Adverse events of the test not described (excluding minor discomforts and inconvenience of venipuncture or noninvasive tests).
e Follow-Up key: 1. Follow-up duration not sufficient with respect to natural history of disease (true-positives, true-negatives, false-positives, false-negatives cannot be determined).
Table 10. Study Design and Conduct Limitations
Study Selectiona Blindingb Delivery of Testc Selective Reportingd Data Completenesse Statisticalf
clonoSEQ Technical Summary   1. Blinding was not described   2. Details from the technical summary are limited and did not discuss the minimal difference of the different thresholds.    
Thompson et al (2019)10, 2. Selection based on availability of tissue samples from prior studies 1. Blinding was not described        
Munir et al (2023)11,   1. Blinding was not described        
The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
a Selection key: 1. Selection not described; 2. Selection not random or consecutive (ie, convenience).
b Blinding key: 1. Not blinded to results of reference or other comparator tests.
c Test Delivery key: 1. Timing of delivery of index or reference test not described; 2. Timing of index and comparator tests not same; 3. Procedure for interpreting tests not described; 4. Expertise of evaluators not described.
d Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.
e Data Completeness key: 1. Inadequate description of indeterminate and missing samples; 2. High number of samples excluded; 3. High loss to follow-up or missing data.
f Statistical key: 1. Confidence intervals and/or p values not reported; 2. Comparison with other tests not reported.

Clinically Useful

A test is clinically useful if the use of the results informs management decisions that improve the net health outcome of care. The net health outcome can be improved if patients receive correct therapy, or more effective therapy, or avoid unnecessary therapy, or avoid unnecessary testing.

Direct Evidence

Direct evidence of clinical utility is provided by studies that have compared health outcomes for patients managed with and without the test. Because these are intervention studies, the preferred evidence would be from RCTs.

No RCTs assessing the clinical utility of MRD by NGS to guide therapy were identified.

Chain of Evidence

Indirect evidence on clinical utility rests on clinical validity. MRD levels that are less than 10-4 are associated with improved PFS compared to patients who have MRD levels greater than 10-4. The studies are insufficient to demonstrate improved prognostic performance at thresholds lower than 10-4.

Section Summary: Next Generation Sequencing to Detect Measurable Residual Disease in Chronic Lymphocytic Leukemia

The evidence on NGS for detection of MRD includes 2 studies that were submitted to the FDA. These studies evaluated the association between the level of MRD detected by NGS in the bone marrow or blood and PFS in samples of blood or bone marrow from completed phase 2 and 3 trials. Both studies demonstrated an association between the level of MRD and PFS with lower risk of progression in patients who exhibit MRD negativity below 10-4 compared to patients who have detectable residual disease.

Evidence is sufficient to support the clinical utility of using NGS to measure MRD for prognosis based on test results at a sensitivity of 10-4. Currently, no additional treatment is offered to eradicate low-level MRD (<10-4) after first-line treatment of CLL. Further study is needed to clarify which threshold of NGS should be considered when risk stratifying patients and whether prognosis based on the more sensitive thresholds improves the net health outcome.

For individuals with CLL who are being monitored for residual disease following treatment who receive NGS for MRD at a threshold of 10-4, the evidence includes analysis of samples from 2 clinical trials. Relevant outcomes are OS, disease-specific survival, test validity, change in disease status, QOL, and treatment-related morbidity. These studies evaluated the association between the level of MRD detected by NGS in bone marrow or blood and progression-free survival (PFS) in completed phase 2 and 3 trials. Both studies demonstrated an association between the level of MRD and PFS with lower risk of progression in patients who exhibit MRD negativity below 10-4 compared to patients who have detectable residual disease. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

Population

Reference No. 3

Policy Statement

 [X] Medically Necesary

 [  ] Investigacional 

For individuals with CLL who are being monitored for residual disease following treatment who receive NGS for MRD at a threshold of less than 10-4, the evidence includes analysis of samples from 2 clinical trials. Relevant outcomes are OS, disease-specific survival, test validity, change in disease status, QOL, and treatment-related morbidity. NGS can be more sensitive than FC to detect the presence of residual leukemic cells, but it is not clear if prognosis is improved at the lower thresholds. Currently, no additional treatment is offered to eradicate low-level MRD (<10-4) after first-line treatment of CLL. Further study is needed to clarify whether MRD at levels lower than 1 in 10,000 cells represents clinically significant disease and if the more sensitive test can be used for prognosis in patients with CLL. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Population

Reference No. 4

Policy Statement

 [  ] Medically Necesary

 [X] Investigacional 

Population Reference No. 5 & 6

Next-Generation Sequencing to Detect Measurable Residual Disease in Multiple Myeloma

Clinical Context and Test Purpose

Multiple myeloma (MM) represents approximately 17% of all hematologic cancers, largely occurring in patients over 60 years of age. It is characterized by the proliferation of plasma cells in the bone marrow producing a monoclonal immunoglobulin. The clonal plasma cells frequently result in extensive skeletal destruction with osteolytic lesions, osteopenia, and/or pathologic fractures; additional complications can include hypercalcemia, renal insufficiency, anemia, and infections.

MM is treatable but is typically incurable, with treatment reserved for patients with symptomatic disease (usually progressive). Without effective therapy, symptomatic patients die within a median of 6 months. Asymptomatic patients are observed because there is little evidence that early treatment of asymptomatic MM prolongs survival compared with therapy delivered at the time of symptoms or end-organ damage. In some patients, an asymptomatic but more advanced premalignant stage is referred to as smoldering MM. Patients with smoldering MM may remain stable for prolonged periods, with an overall risk of disease progression from smoldering to symptomatic MM of 10% per year for the first 5 years, approximately 3% per year for the next 5 years, and 1% for the next 10 years.

Prognosis and treatment for MM depend on risk stratification based on underlying genetic variants, age, performance status, comorbidities, stage, and response to therapy. Patients are assessed to determine eligibility for HCT because HCT has been shown to prolong both event-free and OS compared with chemotherapy alone. The response to treatment is usually determined by a morphologic evaluation and visual quantitation of the percentage of plasma cells in the bone marrow. Most patients with MM will have an initial response to treatment, but will ultimately progress with serial relapse, and will be treated with most available agents at some point during their disease course. Other patients will not respond to initial treatment (refractory disease).

Response to treatment is categorized into clinical response, MRD response, and imaging response. A complete (clinical) response is defined by the International Myeloma Working Group and the National Comprehensive Cancer Network as shown in Table 11.12, MRD response is defined as a CR plus the absence of clonal plasma cells by NGF or NGS at a minimum sensitivity of 1 in 10-5 nucleated cells in bone marrow, and there is a category of “imaging plus MRD-negative” in which patients are determined to have a CR, be MRD negative in the bone marrow, and have also achieved positron emission tomography (PET)/computed tomography (CT)-negativity. "Sustained MRD negativity” is achieved when both imaging plus MRD are negative in assessments that are a minimum of 1 year apart. It is not known whether patients with sustained MRD negative status can be considered cured. MRD measured by NGS is currently used as a surrogate outcome measure in clinical trials, and there are ongoing trials to test the effectiveness of using NGS-MRD to guide therapy.13,

Table 11. Definitions of Complete Response and Measurable Residual Disease Criteria from the International Myeloma Working Group12,
Standard Response Criteria  
Complete response "Negative immunofixation on the serum and urine and disappearance of any soft tissue plasmacytomas and <5% plasma cells in bone marrow aspirates"
MRD Response Criteria (requires a complete response)  
Sequencing MRD-negative Absence of clonal plasma cells with a minimum sensitivity of 1 in 10-⁵ nucleated cells
Imaging plus MRD-negative MRD negativity by NGF or NGS plus imaging criteria
MRD: minimal residual disease; NGF: next-generation flow; NGS: next-generation sequencing

 

 

The main use of measurement of MRD is to inform treatment management.

Measures of MRD can be used to assess whether a patient has responded to treatment, has not fully responded to treatment, or has progressed. The National Comprehensive Cancer Network guidelines provide an analytic framework for the use of MRD in MM.11, If a patient meets the criteria for CR and MRD, the patient could proceed to maintenance therapy or observation. If, however, a patient meets the criteria for nonresponse or for progression, the clinical decision would be to proceed to the next line of therapy for the previously treated disease. The National Comprehensive Cancer Network guidelines recommend follow-up/surveillance after treatment with multiparameter FC (threshold of 10-4), with NGF or NGS used for prognostication (threshold of 10-5) after shared decision with the patient.

The following PICO was used to select literature to inform this review.

Populations

The relevant population of interest is patients who are undergoing or have undergone treatment for MM.

Interventions

The test being considered is MRD assessment by NGS (eg, clonoSEQ). NGS utilizes locus-specific primers for immunoglobulin gene rearrangements, which are rearranged in myeloma patients. Baseline bone marrow samples at the time of high disease load are required in order to identify the dominant clonotype. With the clonoSEQ test, dominant ("clonogenic") sequences can be identified in ~92% of MM patients, while dominant sequences cannot be identified in the other ~ 8% of patients.

Comparators

Evaluation for disease progression in MM typically includes serum protein electrophoresis, serum immunofixation, 24-hour urine protein electrophoresis, urine immunofixation, and serum-free light chain, hemoglobin, serum calcium, and creatinine. A bone marrow aspirate and biopsy is not always needed but can clarify disease status and determine if a change in the cytogenetic characteristics has occurred. MRD detection by NGS would be an adjunct to clinical measures of progression and an alternative to NGF, which has a sensitivity of 10-5.

Outcomes

The general outcomes of interest are clinical progression in the short term and survival at a longer follow-up.

Beneficial outcomes of a true-positive test result (detection of clinically significant disease) would be intensification or continuation of an effective treatment leading to longer PFS. The beneficial outcome of a true-negative test (absence of clinically significant residual disease) is the avoidance of unnecessary treatment and reduction of adverse events.

Harmful outcomes of a false-positive test include an increase or continuation of unnecessary treatment resulting in treatment-related harm. Harmful outcomes of a false-negative test include a reduction in necessary treatment that would delay treatment, with a potential impact in disease progression.

Direct harms of the test are repeated bone marrow biopsy. Harms of repeated bone marrow biopsy may include tenderness or pain, bleeding or bruising, and swelling.

Utility of MRD to guide treatment of MM may be measured in months for progression of the disease, with survival measured in years.

Study Selection Criteria

For the evaluation of the clinical validity of the clonoSEQ test, studies that met the following eligibility criteria were considered:

OR, comparative trials that evaluated health outcomes when therapy was guided by NGS assessment of MRD.

Clinically Valid

A test must detect the presence or absence of a condition, the risk of developing a condition in the future, or treatment response (beneficial or adverse).

Review of Evidence

Martinez-Lopez et al (2014) assessed the time to progression (TTP) stratified by MRD at levels from 10-3 to less than 10-5 and found that the TTP was associated with the level of MRD.14, Specifically, median progression was 27 months for patients with MRD greater than 10-3, 48 months for patients with MRD between 10-3 and 10-5, and 80 months for patients with MRD less than 10-5 , giving a HR of 3.97 for higher levels of MRD (p<.001, see Table 9). In the subgroup of patients with CR, TTP was 131 months in MRD negative patients and 35 months in MRD positive patients (HR of 2.87, p<.001). When compared to multiparameter FC, 82 of 99 results (83%) were concordant. NGS identified an additional 12 patients with MRD that were MRD-negative by FC, while 5 patients were found to be flow MRD+/NGS MRD-. One of 5 flow+/NGS- patients progressed. Patients who were NGS+/flow- had an intermediate TTP (50 months) compared to NGS-negative patients (TTP not reached; p<.0001).

In Perrot et al (2018), a threshold of 10-6 was used to evaluate the association between MRD and PFS, finding that the dichotomous division into MRD positive and MRD negative (no detectable MRD at the limit of detection) was highly predictive of PFS with an HR for MRD negative/MRD positive of 0.19 (p<.001).15, The median PFS was 29 months in patients who were positive for MRD and was not reached among patients with no detectable MRD.

Martinez-Lopez et al (2020) reported a retrospective analysis of patients (N=234) treated at their center for newly diagnosed or relapsed MM who had been evaluated for MRD by NGS.16, MRD assessment by clonoSEQ was performed after a CR, but there was no consistent time after treatment; most were performed within 1 year. Successful identification of at least one trackable sequence in the pretreatment sample was obtained in 234 out of 251 (93%) patients. Sensitivity was assessed at 10-4, 10-5, and 10-6. Out of all patients, 91 (39%) had MRD less than 10-6 and 129 (55%) had MRD less than 10-5. For both newly diagnosed MM and relapsed MM patients, MRD less than 10-5 or less than 10-6 was associated with prolonged survival. In patients who had repeat testing, rising MRD levels preceded clinical relapse by a median of 13 months (range 1 to 28 months). Patients who reached a molecular response at 10-5 had similar outcomes to those who achieved MRD negativity at 10-6.

Cavo et al (2022) analyzed pooled data from 4 phase 3 studies in patients with relapsed or refractory MM who were ineligible for transplant.17, MRD was assessed at a sensitivity of 10-5. Patients who achieved a complete response or better and were MRD negative had improved PFS and an 80% reduction in the risk of disease progression or death compared with those who failed to reach CR or were MRD positive (HR, 0.20; p<.0001).

Oliva et al (2023) reported results of analyses of MRD status from samples available from the FORTE trial.18, The FORTE trial was a phase 2, multicenter RCT including participants with newly diagnosed, transplant-eligible multiple myeloma randomized between 2015 and 2021 to one of three induction-intensification-consolidation strategies. Multiparameter flow cytometry (MFC) status was assessed in patients with at least a very good partial response first at premaintenance and then every 6 months during maintenance treatment until progressive disease. The cut-off for MFC MRD positivity was set at ≥20 clonal plasma cells out of the total of nucleated cells, with a sensitivity of ≥10−5. NGS was performed in a subset of participants with at least a suspected complete response at pre-maintenance and monitored every 6 months during maintenance treatment until progressive disease using the clonoSEQ® assay with sensitivities at 10-5 and 10-6. 2020 samples were available for analysis of MFC MRD status and 728 samples were available for the analysis of the correlation between MFC and NGS in the “suspected complete response population”. Median follow-up was 62 months. The hazard ratios for PFS in MFC-MRD and NGS-MRD-negative vs -positive patients were 0.29 (95% CI, 0.20 to 0.40) and 0.27 (95% CI, 0.18 to 0.39), respectively; see Table 13. Concordance between MFC and NGS is shown in Table 14 and concordance between NGS and NGF is shown in Table 15.

The major limitations of these studies are described in Tables 16 and 17.

Table 12. Characteristics of Studies Assessing NGS for MRD in MM

Study Study Population Design Reference Standard Threshold Test Version
Martinez-Lopez et al (2014)14, Patients with available bone marrow samples from GEM myeloma trialsa Retrospective TTP MRD at 10-3 and 10-5 LymphoSIGHT
Perrot et al (2018)15, Patients with myeloma enrolled in the IFM 2009 clinical trialb Retrospective PFS and OS MRD at 10-6 clonoSEQ
Martinez-Lopez et al (2020) 16, Patients with MM who had been treated at their clinic between 2005 and 2018 (N=234) Retrospective PFS MRD at 10-5 clonoSEQ
Cavo et al (2022)17, Patients with bone marrow samples from POLLUX, CASTOR, ALCYONE, and MAIA trialsc Retrospective PFS MRD at 10-5 clonoSEQ
Oliva et al (2023)18, Patients with bone marrow samples from FORTE trial Retrospective PFS MRD at 10-5 and 10-6 clonoSEQ
 MRD: measurable residual disease; NGS: next-generation sequencing; OS: overall survival; PFS: progression-free survival; TTP: time to progression.
a GEM (Grupo Español deMieloma) myeloma treatment trials
b IFM 2009 was phase 3 trial from the Intergroupe Francophone du Myelome, conducted between 2010 and 2012, which evaluated the role of autologous cell transplantation in patients with newly diagnosed myeloma.
c POLLUX, CASTOR, ALCYONE, and MAIA were daratumumab-based studies in patients with newly diagnosed MM.
Table 13. Results of Prognostic Studies Assessing NGS for MRD in MM
Study N MRD Threshold TTP, mo (95% CI)  
Martinez-Lopez et al (2014)14, 133 >10-3 27  
    10-3 to 10-5 48  
    <10-5 80  
Hazard Ratio for Time to Progression     3.97  
p-Value     <.001  
Subset of patients with CR 26 <10-5 131 (51-154)  
Subset of patients with CR 36 >10-5 35 (30-41)  
Hazard Ratio for Time to Progression     2.87  
p-Value     <.001  
Perrot et al (2018)15, 509 10-6 MRD negative/MRD positive  
Hazard Ratio for Progression Free Survival (95% CI)     0.19 (0.13 to 0.26)  
p-Value     <0.001  
Martinez-Lopez et al (2020) 16,     PFS, mo 3-year survival, %
Newly Diagnosed   <10-6   90% (81% to 98.78%)
    <10-5 87 85.9% (78.2% to 94.5%)
    >10-5 32 46.8% (33.9% to 64.7%)
HR (95% CI)     3.54 (1.94 to 6.45)  
p-Value     <.001  
Relapsed 27/75 (36%) <10-6 not reached  
  35/75 (47%) <10-5 42  
    >10-5 17  
HR (95% CI)     2.45 (1.25 to 4.82)  
p-Value     .01  
Cavo et al (2022)17,     48-month PFS, %  
  2510 10-5    
Complete response or better and MRD negative     70.4  
Less than very good partial response or MRD positive     23.9  
Oliva et al (2023)18,     48-month PFS, % 48-month OS, %
MRD positive     46% 78%
MRD negative     83% 94%
HR (95% CI)     0.27 (0.18 to 0.39) 0·31 (0.17 to 0.54)
p-Value     <.01 <.01
CI: confidence interval; CR: complete response; HR: hazard ratio; MRD: measurable residual disease; NGS: next-generation sequencing; OS: Overall survival; PFS; progression free survival; TTP: time to progression.
Table 14. Concordance Between NGS and FC

Martinez-Lopez (2014))14,

     

 

  Flow Cytometry  
  + - Total

NGS
+ 60 12 72
- 5 22 27
  Total 65 34 99
Oliva (2023)18,        
    Flow Cytometry  
    + - Total

NGS
+ 85 59 144
- 17 428 445
  Total 102 487 589
FC: flow cytometry; NGS: next-generation sequencing.

Kriegsmann et al (2020) found moderate concordance between NGS and NGF in a study of 113 patients with MM (Table 17).19, Concordance between methods was obtained in 68% of patients while discordant results were found in 28 patients (11.2% in each direction). Cohen’s kappa coefficient for interrater agreement between the MRD status of the 2 methods was 0.536 (n = 113, p <.001). A threshold of 10-5 was chosen as the best-fit MRD cut-off for evaluation as it met the international guidelines and resulted in a tolerable proportion of nonassessable cases in both methods (1.6%, n=2 in NGS and 8.0%, n=10 in NGF).

Table 15. Concordance Between NGS and NGF
Kriegsmann (2020)19,      
    NGF  
  + - Total

NGS
+ 42 14 56
- 14 43 57
  Total 56 57  
Oliva (2023)18,        
    NGF  
    + - Total

NGS
+ 32 22 54
- 2 83 85
  Total 34 105 139
NGF: next generation flow cytometry; NGS: next-generation sequencing.
Table 16. Study Relevance Limitations
Study Populationa Interventionb Comparatorc Outcomesd Duration of Follow-Upe
Martinez-Lopez et al (2014)14,       3. No data were reported using a threshold of 10-6 since most of the samples had less input cells than is needed for this level of sensitivity  
Perrot et al (2018)15, 4. The study included patients from the IFM 2009 trial who had at least a very good partial response but did not report separately on patients with a complete response        
Martinez-Lopez et al (2020) 16,     3. No comparison to other tests for MRD    
Cavo et al (2022)17,     3. No comparison to other tests for MRD    
Oliva et al (2023)18, 4. MFC status was assessed in patients with at least a very good partial response and NGS was assessed in patients with at least a suspected complete response        
The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.

a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.
b Intervention key: 1. Classification thresholds not defined; 2. Version used unclear; 3. Not intervention of interest.
c Comparator key: 1. Classification thresholds not defined; 2. Not compared to credible reference standard; 3. Not compared to other tests in use for same purpose.
d Outcomes key: 1. Study does not directly assess a key health outcome; 2. Evidence chain or decision model not explicated; 3. Key clinical validity outcomes not reported (sensitivity, specificity, and predictive values); 4. Reclassification of diagnostic or risk categories not reported; 5. Adverse events of the test not described (excluding minor discomforts and inconvenience of venipuncture or noninvasive tests).
e Follow-Up key: 1. Follow-up duration not sufficient with respect to natural history of disease (true-positives, true-negatives, false-positives, false-negatives cannot be determined).
Table 17. Study Design and Conduct Limitations
Study Selectiona Blindingb Delivery of Testc Selective Reportingd Data Completenesse Statisticalf
Martinez-Lopez et al (2014)14, 2. Selection based on availability of tissue samples from prior studies 1. Blinding not described       1. The analysis by level of MRD does not appear to be prespecified.
Perrot et al (2018)15, 2. Selection based on availability of tissue samples in the original study 1. Blinding not described       1. Post-hoc exploratory analysis, not adjusted for multiple comparisons
Martinez-Lopez et al (2020) 16, 2. Retrospective assessment of clinical data 1. Blinding not described 2. There was no uniform timing of the test.      
Cavo et al (2022)17,     2. MRD assessed at different time points in individual studies.      
Oliva et al (2023)18, 2. Retrospective assessment of clinical data 1. Blinding not described        
MRD: measurable residual disease
The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
a Selection key: 1. Selection not described; 2. Selection not random or consecutive (ie, convenience).
b Blinding key: 1. Not blinded to results of reference or other comparator tests.
c Test Delivery key: 1. Timing of delivery of index or reference test not described; 2. Timing of index and comparator tests not same; 3. Procedure for interpreting tests not described; 4. Expertise of evaluators not described.
d Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.
e Data Completeness key: 1. Inadequate description of indeterminate and missing samples; 2. High number of samples excluded; 3. High loss to follow-up or missing data.
f Statistical key: 1. Confidence intervals and/or p values not reported; 2. Comparison with other tests not reported.

 

 

Clinically Useful

A test is clinically useful if the use of the results informs management decisions that improve the net health outcome of care. The net health outcome can be improved if patients receive correct therapy, or more effective therapy, or avoid unnecessary therapy, or avoid unnecessary testing.

Direct Evidence

Direct evidence of clinical utility is provided by studies that have compared health outcomes for patients managed with and without the test. Because these are intervention studies, the preferred evidence would be from RCTs.

No RCTs assessing the clinical utility of MRD by NGS to guide therapy were identified.

Chain of Evidence

Indirect evidence on clinical utility rests on clinical validity. High concordance has been shown between NGS and FC at a threshold of 10-4, indicating that NGS may be considered an alternative to NGF at this threshold. Retrospective studies also indicate improved PFS when MRD is less than 10-5 compared to patients who have MRD greater than 10-5. This threshold is consistent with current guideline-based care for prognostication. Prospective studies will be needed to determine whether treatment can be guided by this test.

The retrospective studies are insufficient to demonstrate clinical validity at thresholds lower than 10-5. Levels of MRD are associated with average prognosis, but improved performance characteristics have not been demonstrated at lower thresholds. A potential benefit of NGS assessment of MRD would be if patients were able to forgo maintenance therapy if there was no detectable MRD. However, it is unknown whether therapy can be safely guided based on this test.

Section Summary: Next-generation Sequencing to Detect Measurable Residual Disease in Multiple Myeloma

The evidence on NGS for detection of MRD includes 4 published retrospective studies in patients with MM. These studies evaluated the association between the level of MRD detected by NGS in the bone marrow and the TTP or PFS from the completed phase 3 trials or from a clinical population. All of the studies demonstrated an association between the level of MRD and PFS with longer TTP in patients who exhibit MRD negativity below 10-5 or 10-6 compared to patients who have detectable residual disease. There was also high concordance between NGS and FC. Patients who were discordant for the 2 tests had outcomes that were intermediate between patients who were positive for both tests and those who were negative for both tests.

In exploratory analysis of the largest study, the median PFS was 29 months in patients who were positive for MRD and was not reached among patients with no detectable clones, suggesting that assessment of MRD might have utility in guiding therapy. About one-quarter of MRD negative patients progressed within 36 months in these trials, raising questions about whether NGS could be used to guide therapy. It is unknown whether progression is due to very low levels of residual disease or to new clonal rearrangements in MM. Direct evidence from RCTs is needed to evaluate whether patient outcomes are improved by changes in postinduction care (eg, continuing or discontinuing therapy, avoiding unnecessary adverse events) following NGS assessment of residual disease. Trials that test the effectiveness of MRD to guide therapy in MM are ongoing.

For individuals with MM who have achieved a complete response (CR) following treatment who receive NGS for MRD at a threshold of 10-5, the evidence includes a retrospective comparison of NGS and FC data from MM treatment trials and from a clinical series. Relevant outcomes are OS, disease-specific survival, test validity, change in disease status, QOL, and treatment-related morbidity. Concordance has been demonstrated between NGS and the established standard of FC at 10-4 as well as with next generation flow cytometry (NGF) at a threshold of 10-5. PFS in patients with MRD positivity is significantly shorter than in patients who are MRD negative at these thresholds. The relatively small subset of patients who were discordant for FC and NGS results had outcomes that were, on average, midway between patients who were concordant as MRD positive or MRD negative for both tests. Retrospective studies also indicate improved PFS when MRD is less than 10-5 compared to patients who have MRD greater than 10-5. This threshold is consistent with current guideline-based care for prognostication using either NGF or NGS. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

Population

Reference No. 5

Policy Statement

 [X] Medically Necesary

 [   ] Investigacional 

For individuals with MM who have achieved a CR following treatment who receive NGS for MRD at a threshold of less than 10-5, the evidence includes retrospective studies on prognosis. Relevant outcomes are OS, disease-specific survival, test validity, change in disease status, QOL, and treatment-related morbidity. There is some evidence that MRD may be a prognostic marker, but there is insufficient evidence on the number of false positives in patients with CR at the more sensitive threshold provided by NGS for prognostication or to guide therapy. A chain of evidence regarding management changes based on the assessment of MRD with NGS to detect 1 malignant clonal sequence out of 1,000,000 cells cannot be completed. Direct evidence from randomized controlled trials is needed to evaluate whether patient outcomes are improved by changes in postinduction care (eg, continuing or discontinuing therapy, avoiding unnecessary adverse events) following NGS assessment of residual disease at a threshold lower than 10-5. Several trials that will test the effectiveness of NGS to guide therapy in MM are ongoing. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Population

Reference No. 6

Policy Statement

 [  ] Medically Necesary

 [X] Investigacional 

Population Reference No. 7 

Next-Generation Sequencing to Detect Measurable Residual Disease in Diffuse Large B-Cell Lymphoma

Clinical Context and Test Purpose

Lymphoma refers to any cancer that starts in the lymph system and includes 2 broad categories of disease, Hodgkin lymphoma and non-Hodgkin lymphoma.18, There are multiple forms of non-Hodgkin lymphoma with B-cell malignancies comprising 85% of cases.19, Of the B-cell lymphomas, diffuse large B-cell lymphoma (DLBCL) accounts for approximately one-third of cases. DLBCL occurs most commonly in older patients with the mean age of diagnosis of approximately 60 years of age. Although aggressive, DLBCL generally responds well to treatment, and 75% of patients have no signs of disease after initial treatment. Historically, PET and CT imaging have been used to assess lymphoma tumor burden and disease response; however, techniques such as flow cytometry, PCR-based methods, and NGS-based techniques are being increasingly used.20,

Test Purpose

The main use of measurement of MRD with NGS in patients with DLBCL is to inform treatment management.

The following PICO was used to select literature to inform this review.

Populations

The relevant population of interest is patients who are undergoing or have undergone treatment for DLBCL.

Interventions

The test being considered is MRD assessment by NGS (eg, clonoSEQ). NGS utilizes locus-specific primers for immunoglobulin gene rearrangements, which are rearranged in lymphoma patients.

Comparators

Evaluation for disease progression in DLBCL traditionally includes PET/CT scans; however, PCR-based methods and flow cytometry have also been studied for MRD.

Outcomes

The general outcomes of interest are clinical progression in the short term and survival at a longer follow-up.

Beneficial outcomes of a true-positive test result (detection of clinically significant disease) would be intensification or continuation of an effective treatment leading to longer PFS. The beneficial outcome of a true-negative test (absence of clinically significant residual disease) is the avoidance of unnecessary treatment and reduction of adverse events.

Harmful outcomes of a false-positive test include an increase or continuation of unnecessary treatment resulting in treatment-related harm. Harmful outcomes of a false-negative test include a reduction in necessary treatment that would delay treatment, with a potential impact in disease progression.

Utility of MRD to guide treatment of DLBCL may be measured in months for progression of the disease, with survival measured in years.

Study Selection Criteria

For the evaluation of the clinical validity of the clonoSEQ test, studies that met the following eligibility criteria were considered:

OR, comparative trials that evaluated health outcomes when therapy was guided by NGS assessment of MRD.

Clinically Valid

A test must detect the presence or absence of a condition, the risk of developing a condition in the future, or treatment response (beneficial or adverse).

Review of Evidence

There are 2 studies assessing the prognostic value of NGS for MRD specifically in patients with DLBCL. One prospective, single-center, observational study by Chase et al (2021) attempted to correlate MRD with prognosis in patients with newly diagnosed DLBCL receiving conventional treatment; however, attrition limited outcome assessment.21, Only 3 patients had early clinical relapse, and no conclusions can be drawn. Tables 18 and 19 describe the characteristics and results of the other prognostic study in patients with DLBCL, and Tables 20 and 21 describe limitations of this trial.

In a phase 2, single-center, prospective trial in patients with DLBCL undergoing HSCT, Kambhampati et al (2021) assessed 15 patients for MRD with NGS.22, Of the 14 patients with available MRD samples after salvage therapy, 11 were MRD negative and 3 were MRD positive. MRD tests were predictive of survival in these patients.

Table 18. Characteristics of Studies Assessing NGS for MRD in DLBCL

Study Study Population Design Reference Standard Threshold Test Version
Kambhampati et al (2021)25, Patients with relapsed/refractory DLBCL undergoing HSCT enrolled in a phase 2 trial Single-center, prospective PFS/OS NR clonoSEQ
DLBCL: diffuse large B-cell lymphoma; HSCT: hematopoietic stem cell transplant; NR: not reported: OS: overall survival; PFS: progression-free survival.
Table 19. Results of Prognostic Studies Assessing NGS for MRD in DLBCL
Study N Median OS, mo Median PFS, mo
Kambhampati et al (2021)25, 27 (14 with MRD samples after salvage therapy)    
MRD negative   Not reached Not reached
MRD positive   3.5 1.3
 MRD: measurable residual disease; OS: overall survival; PFS: progression-free survival.
Table 20. Study Relevance Limitations
Study Populationa Interventionb Comparatorc Outcomesd Duration of Follow-Upe
Kambhampati et al (2021)25,   1. Threshold not reported 3. No comparator MRD measure    
The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.
b Intervention key: 1. Classification thresholds not defined; 2. Version used unclear; 3. Not intervention of interest.
c Comparator key: 1. Classification thresholds not defined; 2. Not compared to credible reference standard; 3. Not compared to other tests in use for same purpose.
d Outcomes key: 1. Study does not directly assess a key health outcome; 2. Evidence chain or decision model not explicated; 3. Key clinical validity outcomes not reported (sensitivity, specificity, and predictive values); 4. Reclassification of diagnostic or risk categories not reported; 5. Adverse events of the test not described (excluding minor discomforts and inconvenience of venipuncture or noninvasive tests).
e Follow-Up key: 1. Follow-up duration not sufficient with respect to natural history of disease (true-positives, true-negatives, false-positives, false-negatives cannot be determined).
Table 21. Study Design and Conduct Limitations
Study Selectiona Blindingb Delivery of Testc Selective Reportingd Data Completenesse Statisticalf
Kambhampati et al (2021)25,   1. Blinding not described       2. No comparator MRD measure
MRD: measurable residual disease
The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
a Selection key: 1. Selection not described; 2. Selection not random or consecutive (ie, convenience).
b Blinding key: 1. Not blinded to results of reference or other comparator tests.
c Test Delivery key: 1. Timing of delivery of index or reference test not described; 2. Timing of index and comparator tests not same; 3. Procedure for interpreting tests not described; 4. Expertise of evaluators not described.
d Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.
e Data Completeness key: 1. Inadequate description of indeterminate and missing samples; 2. High number of samples excluded; 3. High loss to follow-up or missing data.
f Statistical key: 1. Confidence intervals and/or p values not reported; 2. Comparison with other tests not reported.

Clinically Useful

A test is clinically useful if the use of the results informs management decisions that improve the net health outcome of care. The net health outcome can be improved if patients receive correct therapy, or more effective therapy, or avoid unnecessary therapy, or avoid unnecessary testing.

Direct Evidence

Direct evidence of clinical utility is provided by studies that have compared health outcomes for patients managed with and without the test. Because these are intervention studies, the preferred evidence would be from RCTs.

No RCTs assessing the clinical utility of MRD by NGS to guide therapy were identified.

Chain of Evidence

Indirect evidence on clinical utility rests on clinical validity. Further studies will be needed to determine whether treatment can be guided by this test.

Section Summary: Next-Generation Sequencing to Detect Measurable Residual Disease in Diffuse Large B-Cell Lymphoma

The evidence on NGS for detection of MRD in DLBCL includes an analysis from a single-center, prospective trial that did not include comparison to another MRD measure. Although both PFS and OS correlated with MRD positivity, the trial is limited by its small sample-size and inclusion of only patients eligible for HSCT from a single center.

For individuals with DLBCL who are being monitored for residual disease following treatment who receive NGS for MRD, the evidence includes an analysis from a single-center, prospective trial. Relevant outcomes are OS, disease-specific survival, test validity, change in disease status, QOL, and treatment-related morbidity. Although both PFS and OS correlated with MRD positivity, the trial is limited by its small sample-size and inclusion of only patients eligible for HSCT from a single center. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Population

Reference No. 7

Policy Statement

 [  ] Medically Necesary

 [X] Investigacional 

Population Reference No. 8 

Next-Generation Sequencing to Detect Measurable Residual Disease in Mantle Cell Lymphoma

Clinical Context and Test Purpose

A small percentage of B-cell lymphomas (about 5%) are categorized as mantle cell lymphoma (MCL).19, Similar to DLBCL, it occurs most commonly in patients over 60 years of age and tends to be an aggressive lymphoma; however, the response to treatment has traditionally been poor. Most patients present with advanced stage disease, and treatment is dependent on stage and eligibility for HSCT. Historically, PET and CT imaging have been used to assess lymphoma tumor burden and disease response; however, techniques such as flow cytometry, PCR-based methods, and NGS-based techniques are being increasingly used.20,

The main use of measurement of MRD with NGS in patients with MCL is to inform treatment management.

The following PICO was used to select literature to inform this review.

Populations

The relevant population of interest is patients who are undergoing or have undergone treatment for MCL.

Interventions

The test being considered is MRD assessment by NGS (eg, clonoSEQ). NGS utilizes locus-specific primers for immunoglobulin gene rearrangements, which are rearranged in lymphoma patients.

Comparators

PET and CT imaging have traditionally been used for monitoring and evaluating disease response in lymphoma patients. Evaluation of MRD by PCR-based methods and flow cytometry is also under investigation.

Outcomes

The general outcomes of interest are clinical progression in the short term and survival at a longer follow-up.

Beneficial outcomes of a true-positive test result (detection of clinically significant disease) would be intensification or continuation of an effective treatment leading to longer PFS. The beneficial outcome of a true-negative test (absence of clinically significant residual disease) is the avoidance of unnecessary treatment and reduction of adverse events.

Harmful outcomes of a false-positive test include an increase or continuation of unnecessary treatment resulting in treatment-related harm. Harmful outcomes of a false-negative test include a reduction in necessary treatment that would delay treatment, with a potential impact in disease progression.

Utility of MRD to guide treatment of MCL may be measured in months for progression of the disease, with survival measured in years.

Study Selection Criteria

For the evaluation of the clinical validity of the clonoSEQ test, studies that met the following eligibility criteria were considered:

OR, comparative trials that evaluated health outcomes when therapy was guided by NGS assessment of MRD.

Clinically Valid

A test must detect the presence or absence of a condition, the risk of developing a condition in the future, or treatment response (beneficial or adverse).

Review of Evidence

Characteristics and results of trials evaluating NGS for MRD in MCL are summarized in Tables 22 and 23, and limitations of these trials are summarized in Tables 24 and 25. Smith et. al. (2019) conducted a retrospective review of samples from patients enrolled in the ECOG1411 trial which evaluated MCL patients treated with bendamustine-rituximab induction followed by rituximab (with or without lenalidomide) consolidation and evaluated MRD by both FC and NGS.23, Concordance between tests was high both after cycle 3 and end of induction. MRD status correlated with PFS. For patients who were MRD negative after cycle 3 by either method, PFS was 58.9 months. For those who were MRD positive by NGS, PFS was 26.9 months and PFS was 29.9 months for those who were positive by FC. The authors concluded both NGS and FC were feasible to assess MRD.

Lakhotia et. al. (2022) conducted an exploratory review of circulating tumor DNA analyzed by NGS from a trial of bortezomib induction in 53 MCL patients found patients who had undetectable MRD after 2 induction cycles had longer PRS and OS than those with MRD.24, As this was an exploratory analysis, key details are not included, and no firm conclusions can be drawn.

Table 22. Characteristics of Studies Assessing NGS for MRD in patients with MCL

Study Study Population Design Reference Standard Threshold Test Version
Smith et al (2019)26, Patients with MCL enrolled in ECOG1411 Retrospective PFS MRD at 10-4 "Research version" of clonoSEQ
Lakhotia et al (2022)27, Patients with MCL enrolled in a trial of bortezomib induction treatment Retrospective PFS NR Not specified; however, test supplied by Adaptive Biotechnologies
ECOG: Eastern Cooperative Oncology Group; MCL: mantle cell lymphoma; MRD: measurable residual disease; NR: not reported; PFS: progression free survival.

Table 23. Results of Prognostic Studies Assessing NGS for MRD in patients with MCL
Study N MRD Threshold MRD Negative, (%)a PFS OS
Smith et al (2019)26, 214 MRD at 10-4      
FC     95 (peripheral blood)    
NGS     91 (peripheral blood)/90 (bone marrow)    
MRD negative (by NGS)       58.9 mo  
MRD positive (by NGS)       26.9 mo  
Lakhotia et al (2022)27, 53        
MRD negativeb       2.7 yr 13.8 yrs
MRD positiveb       1.8 yr 7.4 yrs
FC: flow cytometry; MRD: measurable residual disease; NGS: next-generation sequencing; OS: overall survival; PFS: progression free survival.
a Results reported at end of induction.
b After 2 cycles of induction.
Table 24. Study Relevance Limitations
Study Populationa Interventionb Comparatorc Outcomesd Duration of Follow-Upe
Smith et al (2019)26,   2. Unclear if "research version" of clonoSEQ® used in study is same as commercially available test.     1. Data reported from mid-induction or end of induction
Lakhotia et al (2022)27,   1,2      
The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.
b Intervention key: 1. Classification thresholds not defined; 2. Version used unclear; 3. Not intervention of interest.
c Comparator key: 1. Classification thresholds not defined; 2. Not compared to credible reference standard; 3. Not compared to other tests in use for same purpose.
d Outcomes key: 1. Study does not directly assess a key health outcome; 2. Evidence chain or decision model not explicated; 3. Key clinical validity outcomes not reported (sensitivity, specificity, and predictive values); 4. Reclassification of diagnostic or risk categories not reported; 5. Adverse events of the test not described (excluding minor discomforts and inconvenience of venipuncture or noninvasive tests).
e Follow-Up key: 1. Follow-up duration not sufficient with respect to natural history of disease (true-positives, true-negatives, false-positives, false-negatives cannot be determined).
Table 25. Study Design and Conduct Limitations
Study Selectiona Blindingb Delivery of Testc Selective Reportingd Data Completenesse Statisticalf
Smith et al (2019)26,   1. Blinding not described        
Lakhotia et al (2022)27, 2. Selection based on availability of tissue samples in the original study 1. Blinding not described       1. Post-hoc exploratory analysis
The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.
a Selection key: 1. Selection not described; 2. Selection not random or consecutive (ie, convenience).
b Blinding key: 1. Not blinded to results of reference or other comparator tests.
c Test Delivery key: 1. Timing of delivery of index or reference test not described; 2. Timing of index and comparator tests not same; 3. Procedure for interpreting tests not described; 4. Expertise of evaluators not described.
d Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.
e Data Completeness key: 1. Inadequate description of indeterminate and missing samples; 2. High number of samples excluded; 3. High loss to follow-up or missing data.
f Statistical key: 1. Confidence intervals and/or p values not reported; 2. Comparison with other tests not reported.

Clinically Useful

A test is clinically useful if the use of the results informs management decisions that improve the net health outcome of care. The net health outcome can be improved if patients receive correct therapy, or more effective therapy, or avoid unnecessary therapy, or avoid unnecessary testing.

Direct Evidence

Direct evidence of clinical utility is provided by studies that have compared health outcomes for patients managed with and without the test. Because these are intervention studies, the preferred evidence would be from RCTs.

No RCTs assessing the clinical utility of MRD by NGS to guide therapy were identified.

Chain of Evidence

Indirect evidence on clinical utility rests on clinical validity. High concordance has been shown between NGS and FC at a threshold of 10-4, indicating that NGS may be considered an alternative to FC at this threshold. Further studies are needed to determine whether treatment can be guided by this test.

Section Summary: Next-Generation Sequencing to Detect Measurable Residual Disease in Mantle Cell Lymphoma

The evidence on NGS for detection of MRD in patients with MCL includes a retrospective study and an exploratory analysis of patients enrolled in treatment clinical trials. When compared with FC, NGS had strong correlation, and MRD positivity with either method was associated with worse PFS. However, the relevance of these findings to the commercial version of clonoSEQ® is unclear as a "research version" was used in the study. An exploratory analysis in patients with MCL enrolled in a treatment trial found improved survival in patients who were MRD negative after 2 cycles of induction. However, interpretation was limited by imprecision and unspecified NGS testing level.

For individuals with MCL who are being monitored for residual disease the evidence includes retrospective analyses of NGS testing during therapeutic clinical trials. Relevant outcomes are OS, disease-specific survival, test validity, change in disease status, QOL, and treatment-related morbidity. A retrospective analysis of a "research version" of an NGS test has demonstrated concordance between NGS and FC at 10-4 during induction therapy. MRD positivity as determined by either the "research version" of NGS or FC was associated with worse PFS. An exploratory analysis found improved survival in patients who were MRD negative after 2 cycles of induction; however, this is based on a small number of samples with an undefined threshold for NGS testing. Overall, the literature is limited, and guidelines for NGS testing to detect MRD in patients with MCL are lacking. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Population

Reference No. 8

Policy Statement

 [ ] Medically Necesary

 [X] Investigacional 

Supplemental Information

The purpose of the following information is to provide reference material. Inclusion does not imply endorsement or alignment with the evidence review conclusions.

Practice Guidelines and Position Statements

Guidelines or position statements will be considered for inclusion in ‘Supplemental Information' if they were issued by, or jointly by, a US professional society, an international society with US representation, or National Institute for Health and Care Excellence (NICE). Priority will be given to guidelines that are informed by a systematic review, include strength of evidence ratings, and include a description of management of conflict of interest.

International Myeloma Working Group

The International Myeloma Working Group developed consensus criteria for response and minimal residual disease (MRD) assessment in multiple myeloma (Table 26 ).10,

Table 26. IMWG Criteria

Standard Response Criteria  
Complete response "Negative immunofixation on the serum and urine and disappearance of any soft tissue plasmacytomas and <5% plasma cells in bone marrow aspirates"
Stringent complete response "Complete response as defined below plus normal FLC ratio and absence of clonal cells in bone marrow biopsy by immunohistochemistry (κ/λ ratio ≤4:1 or ≥1:2 for κ and λ patients, respectively, after counting ≥100 plasma cells)"
MRD Response Criteria (requires a complete response)  
Sequencing MRD-negative Absence of clonal plasma cells by NGS using the LymphoSIGHT platform (or validated equivalent ) with a minimum sensitivity of 1 in 10⁵ nucleated cells
Imaging plus MRD-negative MRD negativity by NGF or NGS plus imaging criteria
Sustained MRD-negative MRD negativity by NGF or NGS, and by imaging, at a minimum of 1 year apart.
FLC: free light chain; IMWG: International Myeloma Working Group; MRD: minimal residual disease; NGF: next-generation flow; NGS: next-generation sequencing.

 

International Workshop on Chronic Lymphocytic Leukemia

The 2018 guidelines from the International Workshop on Chronic Lymphocytic Leukemia (CLL) have the following recommendations regarding the assessment of MRD:6,

"The complete eradication of the leukemia is a desired end point. Use of sensitive multicolor flow cytometry, PCR [polymerase chain reaction], or next generation sequencing can detect MRD in many patients who achieved a complete clinical response. Prospective clinical trials have provided substantial evidence that therapies that are able to eradicate MRD usually result in an improved clinical outcome. The techniques for assessing MRD have undergone a critical evaluation and have become well standardized. Six-color flow cytometry (MRD flow), allele-specific oligonucleotide PCR, or high-throughput sequencing using the ClonoSEQ assay are reliably sensitive down to a level of 1 CLL cell in 10,000 leukocytes. Refinement and harmonization of these technologies has established that a typical flow cytometry–based assay comprises a core panel of 6 markers (ie, CD19, CD20, CD5, CD43, CD79b, and CD81). As such, patients will be defined as having undetectable MRD (MRD-neg) remission if they have blood or marrow with,1 CLL cell per 10,000 leukocytes."

The National Comprehensive Cancer Network

The National Comprehensive Cancer Network has published guidelines of relevance to this review (see Table 27 ).

Table 27. Recommendations on Assessing Measurable Residual Disease

Guideline Version Recommendation
Acute lymphoblastic leukemia 1,

3.2023

MRD refers to the presence of leukemic cells below the threshold of detection by conventional morphologic methods or standard immunophenotyping.

The most frequently employed methods for MRD assessment include an FDA-approved NGS-based assay to detect fusion genes or clonal rearrangements in Ig and T-cell receptor (TCR) loci (does not require patient-specific primers) (preferred), flow cytometry assays specifically designed to detect MRD immunophenotypes at low frequency, real-time quantitative polymerase chain reaction (RQ-PCR) assays (eg, clonally rearranged Ig, TCR genes), and reverse transcriptase quantitative PCR (RT-qPCR) assays (eg, BCR/ABL1).High sensitivity flow cytometry with validated analysis algorithms or PCR methods can quantify leukemic cells at a sensitivity threshold of 1x10-4 (0.01%) bone marrow mononuclear cells (MNCs). NGS and some PCR methods can detect leukemic cells at a sensitivity threshold of 1x10-6 (0.0001%) MNCs.

If MRD is negative by flow cytometry, an FDA-approved NGS assay should be considered to confirm negativity.
Chronic lymphocytic leukemia/small lymphocytic lymphoma 8,

3.2023

Evidence from clinical trials suggests that undetectable MRD in the peripheral blood after the end of treatment is an important predictor of treatment efficacy. MRD evaluation should be performed using an assay with a sensitivity of 10-4 according to the standardized ERIC method or standardized NGS method.
Multiple myeloma 28,

1.2024

Consider baseline clone identification and storage of aspirate sample for future minimal residual disease (MRD) testing by NGS.

Surveillance for smoldering disease: Bone marrow aspirate and biopsy with FISH, SNP array, NGS, or multiparameter flow cytometry may be used as clinically indicated.

Consider MRD testing as indicated for prognostication after shared decision with patient.International Myeloma Working Group (IMWG) response criteria:
Flow MRD-negative: Absence of phenotypically aberrant clonal plasma cells by NGF on bone marrow aspirates using the EuroFlow standard operation procedure for MRD detection in multiple myeloma (or validated equivalent method) with a minimum sensitivity of 1 in 105 nucleated cells or higher.
Sequencing MRD-negative: Absence of clonal plasma cells by NGS on bone marrow aspirate in which presence of a clone is defined as less than two identical sequencing reads obtained after DNA sequencing of bone marrow aspirates using a validated equivalent method with a minimum sensitivity of 1 in 105 nucleated cells or higher.

B-cell lymphomas 29, 6.2023 MRD surveillance is not included in the current guidelines.
ALL: acute lymphoblastic leukemia, CR: complete response; ERIC: European Research Initiative on CLL; FC: flow cytometry; FISH: fluorescence in situ hybridization; MRD: measurable residual disease; NGF: next generation flow; NGS: next-generation sequencing; PCR: polymerase chain reaction; SNP: single nucleotide polymorphism.

 

U.S. Preventive Services Task Force Recommendations

Not applicable.

Medicare National Coverage

Molecular Diagnostic Services Program has determined that clonoSEQ Assay testing is reasonable and necessary when performed on bone marrow specimens in patients with B-Cell acute lymphoblastic leukemia (ALL), CLL, or multiple myeloma. Medicare will pay for a single episode of testing using clonoSEQ for a patient with ALL, CLL or multiple myeloma when clonoSEQ is being used according to its U.S. Food and Drug Administration cleared indications and clinical guidelines. An episode of testing will typically require a baseline assay and 3 follow-up assays.

Ongoing and Unpublished Clinical Trials

Some currently ongoing and unpublished trials that might influence this review are listed in Table 20.

Table 28. Summary of Key Trials
NCT No. Trial Name Planned Enrollment Completion Date
Ongoing      
NCT04545333a Real World Observational Study Using clonoSEQ® Next Generation Sequencing in Hematologic Malignancies: The 'Watch' Registry 528 Dec 2024
NCT05625971 Non-Invasive Minimal Residual Disease (MRD) Assessment in Multiple Myeloma Via Functional Imaging and Liquid Biopsy 88 Sep 2024
NCT03509961 A Phase II Pilot Trial to Estimate Survival After a Non-total Body Irradiation (TBI) Based Conditioning Regimen in Patients Diagnosed With Acute Lymphoblastic Leukemia (ALL) Who Are Pre-allogeneic Hematopoietic Cell Transplantation (HCT) Next-generation-sequence (NGS) Minimal Residual Disease (MRD) Negative (ENRAD) 95 Jul 2026
NCT05255354 Optimizing ctDNA-based MRD Assessment in DLBCL, MCL, and FL Patients Undergoing CAR Therapy 300 Mar 2027
NCT: national clinical trial.
a Denotes industry-sponsored or cosponsored trial.

References

  1. National Comprehensive Care Network. NCCN Clinical Practice Guidelines in Oncology: Acute Lymphoblastic Leukemia. Version 3.2023. https://www.nccn.org/professionals/physician_gls/pdf/all.pdf. Accessed October 18, 2023.
  2. Berry DA, Zhou S, Higley H, et al. Association of Minimal Residual Disease With Clinical Outcome in Pediatric and Adult Acute Lymphoblastic Leukemia: A Meta-analysis. JAMA Oncol. Jul 13 2017; 3(7): e170580. PMID 28494052
  3. Wood B, Wu D, Crossley B, et al. Measurable residual disease detection by high-throughput sequencing improves risk stratification for pediatric B-ALL. Blood. Mar 22 2018; 131(12): 1350-1359. PMID 29284596
  4. Pulsipher MA, Carlson C, Langholz B, et al. IgH-V(D)J NGS-MRD measurement pre- and early post-allotransplant defines very low- and very high-risk ALL patients. Blood. May 28 2015; 125(22): 3501-8. PMID 25862561
  5. Pulsipher MA, Han X, Maude SL, et al. Next-Generation Sequencing of Minimal Residual Disease for Predicting Relapse after Tisagenlecleucel in Children and Young Adults with Acute Lymphoblastic Leukemia. Blood Cancer Discov. Jan 2022; 3(1): 66-81. PMID 35019853
  6. Liang EC, Dekker SE, Sabile JMG, et al. Next-generation sequencing-based MRD in adults with ALL undergoing hematopoietic cell transplantation. Blood Adv. Jul 25 2023; 7(14): 3395-3402. PMID 37196642
  7. Hallek M, Cheson BD, Catovsky D, et al. iwCLL guidelines for diagnosis, indications for treatment, response assessment, and supportive management of CLL. Blood. Jun 21 2018; 131(25): 2745-2760. PMID 29540348
  8. National Comprehensive Care Network. NCCN clinical care practice guidelines in Oncology: Chronic lymphocytic leukemia/ small lymphocytic lymphoma. Version 3.2023. https://www.nccn.org/professionals/physician_gls/pdf/cll.pdf. Accessed October 21, 2023.
  9. clonoSEQ Assay: Technical Information. https://www.clonoseq.com/technical-summary/ Accessed October 18, 2023.
  10. Thompson PA, Srivastava J, Peterson C, et al. Minimal residual disease undetectable by next-generation sequencing predicts improved outcome in CLL after chemoimmunotherapy. Blood. Nov 28 2019; 134(22): 1951-1959. PMID 31537528
  11. Munir T, Moreno C, Owen C, et al. Impact of Minimal Residual Disease on Progression-Free Survival Outcomes After Fixed-Duration Ibrutinib-Venetoclax Versus Chlorambucil-Obinutuzumab in the GLOW Study. J Clin Oncol. Jul 20 2023; 41(21): 3689-3699. PMID 37279408
  12. Kumar S, Paiva B, Anderson KC, et al. International Myeloma Working Group consensus criteria for response and minimal residual disease assessment in multiple myeloma. Lancet Oncol. Aug 2016; 17(8): e328-e346. PMID 27511158
  13. Bal S, Weaver A, Cornell RF, et al. Challenges and opportunities in the assessment of measurable residual disease in multiple myeloma. Br J Haematol. Sep 2019; 186(6): 807-819. PMID 31364160
  14. Martinez-Lopez J, Lahuerta JJ, Pepin F, et al. Prognostic value of deep sequencing method for minimal residual disease detection in multiple myeloma. Blood. May 15 2014; 123(20): 3073-9. PMID 24646471
  15. Perrot A, Lauwers-Cances V, Corre J, et al. Minimal residual disease negativity using deep sequencing is a major prognostic factor in multiple myeloma. Blood. Dec 06 2018; 132(23): 2456-2464. PMID 30249784
  16. Martinez-Lopez J, Wong SW, Shah N, et al. Clinical value of measurable residual disease testing for assessing depth, duration, and direction of response in multiple myeloma. Blood Adv. Jul 28 2020; 4(14): 3295-3301. PMID 32706892
  17. Cavo M, San-Miguel J, Usmani SZ, et al. Prognostic value of minimal residual disease negativity in myeloma: combined analysis of POLLUX, CASTOR, ALCYONE, and MAIA. Blood. Feb 10 2022; 139(6): 835-844. PMID 34289038
  18. Oliva S, Genuardi E, Paris L, et al. Prospective evaluation of minimal residual disease in the phase II FORTE trial: a head-to-head comparison between multiparameter flow cytometry and next-generation sequencing. EClinicalMedicine. Jun 2023; 60: 102016. PMID 37396800
  19. Kriegsmann K, Hundemer M, Hofmeister-Mielke N, et al. Comparison of NGS and MFC Methods: Key Metrics in Multiple Myeloma MRD Assessment. Cancers (Basel). Aug 18 2020; 12(8). PMID 32824635
  20. Costa LJ, Chhabra S, Medvedova E, et al. Minimal residual disease response-adapted therapy in newly diagnosed multiple myeloma (MASTER): final report of the multicentre, single-arm, phase 2 trial. Lancet Haematol. Sep 27 2023. PMID 37776872
  21. Hematologic Cancer Incidence, Survival, and Prevalence. Centers for Disease Control and Prevention. Accessed November Oct 18, 2023. https://www.cdc.gov/cancer/uscs/about/data-briefs/no30-hematologic-incidence-surv-prev.htm
  22. Types of B-cell lymphoma. American Cancer Society. Revised January 19, 2019. Accessed October 18, 2023. https://www.cancer.org/cancer/non-hodgkin-lymphoma/about/b-cell-lymphoma.html
  23. Herrera AF, Armand P. Minimal Residual Disease Assessment in Lymphoma: Methods and Applications. J Clin Oncol. Dec 01 2017; 35(34): 3877-3887. PMID 28933999
  24. Chase ML, Merryman R, Fisher DC, et al. A prospective study of minimal residual disease in patients with diffuse large B-cell lymphoma using an Ig-NGS assay. Leuk Lymphoma. Feb 2021; 62(2): 478-481. PMID 33236969
  25. Kambhampati S, Hunter B, Varnavski A, et al. Ofatumumab, Etoposide, and Cytarabine Intensive Mobilization Regimen in Patients with High-risk Relapsed/Refractory Diffuse Large B-Cell Lymphoma Undergoing Autologous Stem Cell Transplantation. Clin Lymphoma Myeloma Leuk. Apr 2021; 21(4): 246-256.e2. PMID 33288485
  26. Smith M, Jegede O, Parekh, et al. Minimal Residual Disease (MRD) Assessment in the ECOG1411 Randomized Phase 2 Trial of Front-Line Bendamustine-Rituximab (BR)-Based Induction Followed By Rituximab (R) Lenalidomide (L) Consolidation for Mantle Cell Lymphoma (MCL). 2019;134(Suppl_1):751. https://ashpublications.org/blood/article/134/Supplement_1/751/427083/Minimal-Residual-Disease-MRD-Assessment-in-the. Accessed October 18, 2023.
  27. Lakhotia R, Melani C, Dunleavy K, et al. Circulating tumor DNA predicts therapeutic outcome in mantle cell lymphoma. Blood Adv. Apr 26 2022; 6(8): 2667-2680. PMID 35143622
  28. National Comprehensive Care Network. NCCN Clinical Practice Guidelines in Oncology: Multiple Myeloma. Version 1.2024. https://www.nccn.org/professionals/physician_gls/pdf/myeloma.pdf. Accessed October 19, 2023.
  29. National Comprehensive Care Network. NCCN clinical care practice guidelines in Oncology: B-cell lymphomas. Version 6.2023. https://www.nccn.org/professionals/physician_gls/pdf/b-cell.pdf. Accessed October 20, 2023.

Codes

Codes Number Description
CPT 81479 Unlisted molecular pathology procedure
  81599 Unlisted multianalyte assay with algorithmic analysis
  0364U Oncology (hematolymphoid neoplasm), genomic sequence analysis using multiplex (PCR) and next-generation sequencing with algorithm, quantification of dominant clonal sequence(s), reported as presence or absence of minimal residual disease (MRD) with quantitation of disease burden, when appropriate
HCPCS No code  
ICD-10-CM C81.00-C96.9 Lymphoma, Leukemia, and Myeloma code range
ICD-10-PCS   There are no inpatient codes for laboratory services
Type of Service Outpatient  
Place of Service Laboratory

Applicable Modifiers

N/A

Policy History

Date

Action

Description

01/09/2024 Replace policy

Policy updated with literature through October 18, 2023; references added. Policy statements edited to clarify that MRD testing with NGS for individuals with diffuse large B-cell lymphoma and mantle cell lymphoma is INV at any sensitivity threshold. Removed 0171U
 

01/04/2023

Annual Review

Policy updated with literature through November 2, 2022; references added. The indications of diffuse large B-cell lymphoma and mantle cell lymphoma were added, and investigational policy statements added for these indications. Effective date for 0171U was deleted.

01/04/2022

Annual Review

Policy updated with literature review through October 20, 2021; NCCN references updated. Minor editorial changes to policy statements, intent unchanged.

01/15/2021

Annual Review

Policy updated with literature review through October 12, 2020; references added. The indication of chronic lymphocytic leukemia was added to the policy at a threshold of 10-4. The threshold for measurable residual disease detection in patients with multiple myeloma was changed to 10-5.

12/18/2020

Annual Review

Unchanged Policy

12/18/2019

Policy Created

New Policy