The Terry Fox Pan-Canadian Multiple Myeloma Molecular Monitoring Study
Conditions: Multiple Myeloma
Sponsor: Horizon Health Network

 
 
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THE TERRY FOX PAN-CANADIAN MULTIPLE MYELOMA MOLECULAR 
MONITORING COHORT STUDY (THE M4 STUDY) 
 
 
 
PROJECT LEADER:  
 
Tony Reiman 
 
    PRINCIPAL INVESTIGATORS:  
  
Donna Reece 
 
  
Nizar Bahlis 
 
  
François Bénard 
 
 
 
 
 
 
 
Suzanne Trudel 
 
 
CO-INVESTIGATORS: 
 
Aldo Del Col 
 
 
 
Jonathan Sussman 
 
 
 
Trevor Pugh 
 
 
 
Chris Venner 
 
 
 
Rodger E. Tiedemann 
 
 
 
Matthew Cheung 
 
 
SUPPORTED BY:  
 
Terry Fox Research Institute 
 

 
 
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TABLE OF CONTENTS 
 
1.0 
OBJECTIVES 
1.1 
Primary Objective 
1.2 
Secondary Objectives 
1.3 
Study Summary 
 
2.0 
BACKGROUND INFORMATION AND RATIONALE 
2.1 
Disease Characterization and Monitoring in Multiple Myeloma 
2.2 
The Search for Better Methods to Monitor Minimal Residual Disease 
2.2.1 
Multiparameter Flow Cytometry 
2.2.2 
Immunoglobulin Gene Sequencing  
2.2.3 
Whole Body Imaging of Myeloma to Monitor Disease 
2.2.4 
Improving Patient Outcomes through MRD Monitoring 
2.3 
Developing New Approaches to Myeloma Molecular Characterization and Monitoring 
 
2.3.1 
Monitoring Mechanisms of Drug Resistance 
2.3.2 
Circulating Tumour DNA (ctDNA) Sequencing Panel 
2.3.3 
Multiple Myeloma Progenitors 
 
3.0 
STUDY POPULATION 
3.1 
Eligibility Criteria 
3.2 
Informed Consent 
 
4.0 
ENTRY AND REGISTRATION PROCEDURES 
 
5.0 
PLAN FOR CLINICAL EVALUATION AND DATA COLLECTION  
 
Table 1: Schedule of Events, Treatment and Data Collection 
 
6.0 
CRITERIA FOR MEASUREMENT OF STUDY ENDPOINTS 
 
Table 2: Required Baseline and Follow-up Tests for Response Assessment (Kumar et al., 2016) 
 
7.0 
STATISTICAL CONSIDERATIONS 
7.1  
Objectives and Design 
7.2  
Primary Endpoints and Analyses 
7.3 
Sample Size and Power  
7.4  
Secondary Endpoints and Analyses 
 
8.0 
ETHICAL, REGULATORY AND ADMINISTRATIVE ISSUES 
8.1 
Inclusivity in Research 
8.2 
Obtaining Informed Consent 
8.3 
Discontinuation of the Study 
8.4 
Retention of Patient Records and Study Files 
 
9.0 
REFERENCES  
 
I 
DEFINITION OF MULTIPLE MYELOMA 
II          LAY SUMMARY 
III  
CONTACT INFORMATION FOR COORDINATING CENTRE AND SITES

 
 
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1.0 
OBJECTIVES 
 
1.1  
Primary Objective 
 
To compare PET scans, immunoglobulin gene sequencing (IgS), and multiparameter flow 
cytometry (MFC) – alone, and in combination – to detect minimal residual disease (MRD) in 
multiple myeloma patients. 
 
1.2   
Secondary Objectives 
 
 
To explore mechanisms of drug resistance, circulating tumour DNA analyses, and 
characterization of myeloma progenitors as potential future additions to myeloma characterization 
and monitoring protocols. 
 
To establish the health care costs and benefits associated with MRD assessment. 
 
To measure quality of life experienced by MM patients undergoing MRD testing, as it relates to 
treatment effects, their disease, and their individual patient characteristics.  
 
1.3 
Study Summary 
 
This prospective cohort study aims to enroll 250 newly diagnosed MM patients across Canada. 
Blood and bone marrow biospecimens will be collected at multiple time points from each patient 
for research. PET scans will be performed on a subset of patients at defined time points. 
Questionnaire data will be collected to inform economic and quality of life analysis of the patient 
cohort. IgS and MFC MRD assays will be performed on the collected bone marrow specimens 
and their relative sensitivity and cost will be compared to one another and to PET scans. An 
algorithm for integrating these different methods of MRD evaluation into clinical practice will be 
developed that strikes the best balance in terms of diagnostic and therapeutic utility, cost and 
quality of life in the Canadian context. 
 
Additional research exploring mechanisms of drug resistance, profiling of circulating tumour 
DNA, and characterizing myeloma progenitor populations that persist despite treatment will be 
conducted. These promising areas of investigation aim to bring more novel methods of myeloma 
disease characterization and monitoring closer to clinical application. 
 
This protocol outlines the study procedures for participating clinical sites regarding patient 
selection, enrollment, informed consent, collection of study data and biological specimens for 
research. Some information is included throughout this protocol document in brief, regarding the 
planned laboratory research and analysis plan. The Research and Development (R&D) Plan for 
this study, which contains much more detailed and complete information about the planned 
research, is being provided to the clinical sites along with this protocol. The R&D Plan must be 
submitted along with this protocol to the local Research Ethics Board and any other institutional 
review committee as required for local study activation. This protocol document and key 
attachments (myeloma diagnostic criteria, schedule of events, informed consent document, 
laboratory manual) includes the information that will be needed on a daily basis to enable sites to 
enroll patients to this study. 
 

 
 
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It is important to note that clinical data on patients in the M4 study will be collected by also 
enrolling them in the separate Canadian Multiple Myeloma Database (CMM-DB) study, which 
has its own protocol and informed consent process. Sites participating in M4 must also participate 
in the CMM-DB. M4 data will subsequently be linked to CMM-DB patient outcomes data for 
analysis. No identifying patient information will be collected in the M4 study, and each patient 
will be assigned an alphanumeric identifier code that can only be linked back to the patient by the 
study team at the participating clinical site. The M4 patient identifier will be entered into the 
CMM-DB and used to link the two datasets. 
 
2.0 
BACKGROUND INFORMATION AND RATIONALE 
 
2.1 
Disease Characterization and Monitoring in Multiple Myeloma 
 
Multiple myeloma (MM) is characterized by the accumulation of malignant, monoclonal plasma 
cells in the bone marrow (BM) with unique, patient-specific rearrangements of immunoglobulin 
(Ig) heavy and light chain genes. Most MM patients’ serum contains a preponderance of secreted 
monoclonal immunoglobulin (M protein), including both intact immunoglobulin and free light 
chains. [González et al., 2007] For many years, standard MM disease monitoring involved BM 
aspirates and biopsies to assess the abundance of plasma cells, and the quantitation of serum M 
protein using electrophoresis. However, while the measurement of M protein by electrophoresis 
generally reflects the abundance of monoclonal plasma cells, it is not comparable between 
patients, and does not always adequately reflect changes in disease burden even within the same 
patient. The development of a robust serum free light chain (sFLC) assay improves sensitivity but 
is still limited, as there are some patients in whom little or no myeloma Ig is secreted [Rajkumar 
et al., 2011]; most patients go on to relapse despite negative electrophoresis results.  
 
2.2 
The Search for Better Methods to Monitor Minimal Residual Disease 
 
In patients who have a complete response to therapy (as defined by electrophoresis and sFLC 
assays), more sensitive methods can detect and quantify MRD – and there is now a convergence 
of highly effective myeloma therapies that produce deep remissions and advances in the 
technology of MRD monitoring.  
 
2.2.1 
Multiparameter Flow Cytometry 
For many years, BM flow cytometry has been used to detect and quantify clonal plasma cells, as 
a means of diagnosing MM and monitoring MRD. Earlier versions of MFC incorporated 2 to 4 
colour instruments, allowing the simultaneous detection of a limited number of plasma cell 
surface proteins using fluorescent antibodies, with sensitivities of ~1:10,000 cells. [Rajkumar et 
al., 2011] Multiparameter, 4-6 colour BM MFC for MRD post-transplant was found to be a 
powerful prognostic marker in the UK Myeloma IX [Rawstron et al., 2013; Rawstron et al., 
2015] study and the Spanish Grupo Español de Mieloma (GEM2000/GEM2005) [Paiva et al., 
2008] studys. Newer MFC techniques using at least 8 colours to identify residual plasma cells 
have sensitivities comparable to conventional BM IgH polymerase chain reactions (PCR) at 1 in 
100,000 cells, with the advantages of being less expensive and applicable to most patients but 
requiring the analysis of freshly obtained marrow. [Mailankody et al., 2015] The most current 
methods using 10-12 colour MFC (“Next generation flow”, “Eurotube”) are proposed to have 
sensitivities of ~1 in 1 million cells, although prospective validation of this level of sensitivity is 
still needed. Post-transplant MFC can discriminate between patients destined for long-term 

 
 
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survival and those likely to have early relapse, particularly when paired with a thorough baseline 
assessment of myeloma cell biology. 
 
2.2.2 
Immunoglobulin Gene Sequencing  
Next-generation IgS is being validated in several patient cohorts and again demonstrates the 
powerful prognostic significance of obtaining the deepest possible remission. [Schinke et al., 
2015] Amplification of Ig heavy and light chain variable sequences followed by next-generation 
sequencing can identify unique sequences that characterize an individual patient myeloma clone 
in >90% of cases without the need to develop consensus primers, a vast improvement in 
applicability over older PCR-based methods. [Martinez-Lopez et al., 2014] Further, the ability to 
sequence individual DNA strands allows for quantification of clonal sequences without needing 
to develop a standard qPCR curve for each patient. The sensitivity of this method for clonal 
sequence detection is as low as 1 clonal sequence per million cells. Intriguingly, as Ig transcripts 
are highly abundant in myeloma cells, the sensitivity of RNA-based IgS is probably even greater 
(though less quantitative) than that for DNA. Blood-based IgS with DNA or RNA is comparably 
sensitive to 6-colour BM MFC and holds promise as a means to reduce the needed frequency of 
BM examinations for sensitive disease monitoring. [Vij et al., 2014]  
 
Comparing MFC and IgS, MFC is applicable to virtually all patients and is widely available 
(though many Canadian laboratories would require technology upgrades to implement 10-12 
colour MFC). MRD can be assayed by MFC without the need to compare to the diagnostic 
sample but requires a fresh sample. On the other hand, IgS is currently felt to be more sensitive; 
in the Intergroupe Francophone Du Myélome/Dana-Farber Cancer Institute (IFM/DFCI) 2009 
study, IgS has been found to be more sensitive than 7-colour MFC and to discriminate patients 
with better or worse prognoses depending on IgS-defined MRD status, even amongst MFC-
defined MRD-negative patients. [Avet-Loiseau et al., 2015] IgS can also be conducted using 
frozen material, but is more costly and requires a pre-treatment sample; in 5-10% of patients the 
clonal sequence cannot be determined for IgS. Nonetheless, while the expense and availability of 
this technology is currently limiting, it is expected that these limitations will be rapidly overcome 
as next generation sequencing is increasingly incorporated into clinical laboratories. 
 
2.2.3 
Whole Body Imaging of Myeloma to Monitor Disease 
Another approach to monitoring MM disease burden is diagnostic imaging, which can detect 
disease outside of BM and blood, and has the potential to overcome sampling error inherent in 
BM aspiration. The most promising imaging modality for the detection, staging, prognosis and 
treatment response assessment of MM is PET, specifically 18F-FDG PET/CT. 18F-FDG is taken 
up by metabolically active myeloma cells, revealing their anatomic distribution particularly when 
combined with concomitant CT imaging. Clearance of 18F-FDG-PET-detected myeloma 
following treatment provides prognostic information that is potentially comparable or 
complementary to that achieved with blood and BM-based assays. An Italian study of patients 
undergoing autologous stem cell transplant (ASCT) initially demonstrated the potential power of 
post-transplant 18F-FDG-PET, [Zamagni et al., 2015] and a recent analysis of a larger French 
study in collaboration with the Dana-Farber Cancer Institute has shown similar results. [Moreau 
et al., 2015] In contrast, a smaller study incorporating highly active novel agents without 
transplant at Memorial Sloan-Kettering Cancer Centre suggested that 18F-FDG-PET did not add 
to the information gained from molecular MRD monitoring. [Korde et al., 2015] 
 
 
 

 
 
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2.2.4 
Improving Patient Outcomes through MRD Monitoring 
The results of large randomized studies have made it customary for clinicians to offer continuous, 
indefinite therapy, yet there is research to suggest that this practice may not be optimal for all 
MM patients. Mayo Clinic data using conventional electrophoresis and immunofixation results to 
assess remission status post-ASCT, without MFC or IgS, demonstrated high rates of overall 
survival (OS) even without maintenance therapy for those in a conventionally defined stringent 
complete response (sCR). [Kapoor et al., 2013] The UK and Spanish studies demonstrated that 
MRD assays can identify the subset of patients in CR who achieve these excellent results, with or 
without maintenance therapy. In the UK study, PFS appeared superior with the addition of 
maintenance therapy even in patients who achieved MRD-negative status, but OS remained 
excellent in MRD-negative patients even without maintenance. A large IFM/DFCI randomized 
study incorporating MRD testing following discontinuation of maintenance therapy after 12 
months recently demonstrated that with modern frontline therapy, MRD-negative status with 
either 18F-FDG-PET or IgS predicts high rates of PFS, with MRD-positive patients showing 
significant relapse rates after stopping maintenance therapy. [Avet-Loiseau et al., 2015] Taken 
together, these results suggest that standard risk, MRD-negative patients might not need indefinite 
therapy. Conversely, in the UK study high-risk patients who remained MRD-positive had such 
low PFS rates that this group of patients should potentially be targeted for identification of new 
treatment strategies. An algorithm indicating when each of these assays should be performed 
during the clinical course can become the standard for adoption into future clinical studies, and 
indeed those conducted globally, as well as in clinical practice.  
 
2.3 
Developing New Approaches to Myeloma Molecular Characterization and Monitoring 
 
The heterogeneity of the myeloma clone within a given patient is becoming better understood and 
will clearly have therapeutic implications; it is crucial to understand the characteristics of those 
MM cells that survive therapy and mediate relapse, and how to best target these cells. The 
mechanisms of action and resistance to current and future therapies continue to be elucidated and 
have yet to be incorporated into clinical practice, but will be key to understanding in real time 
how myeloma cells are escaping therapy, so that clinicians can intervene early to improve patient 
outcomes. Building upon the MRD monitoring component of the present study, there will also be 
several novel lines of investigation integrated into the cohort, to identify more sophisticated ways 
to characterize and monitor MM clones in each patient.  
 
2.3.1 
Monitoring Mechanisms of Drug Resistance 
While lenalidomide is deemed to be the current “standard” maintenance regimen post-transplant, 
it remains unclear which patients can benefit from this costly approach. Further, the majority of 
patients acquire resistance to IMiDs within a couple of years of initiating therapy. [Benboubker et 
al., 2014] Based on previous work, IMiD resistance appears to result from one of three events:  
 
1. Loss or decreased expression of the substrate receptor cereblon (CRBN), the adaptor within 
the Cul4a cullin-RING finger ubiquitin E3 ligase that is required for IMiD activity (~ 30% of 
patients);  
 
2. Splicing of exon 10 within the CRBN IMiD binding domain (also known as thalidomide 
binding domain or TBD) (~ 20% patients); and  
 

 
 
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3. Up-regulation of c-MYC expression or a “switch” in the enhancer or superenhancer, 
converting MYC transcription from an IKZF1-responsive to an IKZF1-non-responsive 
enhancer. (~50% patients).  
 
The mechanisms that lead to resistance to IMiDs had remained largely elusive; decreased 
expression of CRBN is not the sole mechanism. [Bolli et al., 2014; Chapman et al., 2011] It is 
proposed in this study that it is possible to reliably identify these events and hence accurately 
predict IMiD resistance through genomic studies. This will then not only allow precise and 
rational drug selection but will also lead to the discovery of novel means to enhance the activity 
and/or overcome the resistance to this class of drugs, as well as provide the clinician with a 
valuable tool to adjust therapy prior to the development of clinical resistance and organ damage. 
 
2.3.2 
Circulating Tumour DNA (ctDNA) Sequencing Panel 
With the development of sensitive molecular platforms, it is now possible to detect cancer-
associated genetic alterations from cell-free DNA (cfDNA) (e.g., point mutations, copy number 
variations, chromosomal rearrangements), offering the potential for blood-based biomarkers. 
[Schwarzenbach et al., 2011] A number of studies have shown correlations between the presence 
of tumor-associated genetic alterations in blood and PFS/OS in breast cancer patients. 
[Schwarzenbach et al., 2012; Silva et al., 2002] Similarly, mutations present in plasma of 
advanced-stage non-small cell lung cancer (NSCLC) patients predicts for poor outcome to first-
line chemotherapy. [Nygaard et al., 2013]  
 
Further studies in diffuse large B-cell lymphoma, colon and breast cancer have demonstrated the 
utility of cfDNA for detection of residual disease and as a powerful predictor of recurrence. 
[Cristofanilli et al., 2004; Reinert et al., 2015; Roschewski et al., 2015] Additionally, information 
acquired from a single biopsy provides a spatially and temporally limited snapshot of a tumor and 
might fail to reflect its heterogeneity. The requirement of painful BM aspirates for surveillance 
can result in the refusal of patients to provide sequential BM samples. The use of blood-based 
biomarkers can avoid the limitations of traditional “single-site” biopsy and allow for non-invasive 
serial sampling and analysis of the entire tumor genome.  
 
The investigators recently have employed a more flexible, scalable strategy of ultra-deep, full-
length gene sequencing of ctDNA from patients with MM, as an alternative to BM aspirates 
currently used for clinical testing. A clinical-grade ctDNA sequencing panel to query all frequent 
genomic alterations in MM and thus possibly guide personalized approaches to MM care (with a 
particular focus on prognostic markers, recurrent actionable somatic mutations, MRD assessment 
and genomic alterations associated with drug sensitivity) will be applied to patients in the present 
study.  
 
2.3.3 
Multiple Myeloma Progenitors 
The absence of a cure in the vast majority of patients, despite advances in therapy and the 
realization of deep clinical responses, points to the existence of drug-resistant tumor cells with 
tumor initiating capability, [Matsui et al., 2008] though these cells have remained elusive and 
poorly characterized in MM. In previous work, phenotypic or functionally distinct subpopulations 
of tumor clone cells (“progenitors”) in MM were identified, which recapitulate the physiologic 
maturation stages between B cells and plasma cells (PCs) and that include Xbp1s- MM cells that 
appear innately insensitive to PIs. [Leung-Hagesteijn et al., 2013] These drug-resistant Xbp1s- 
MM progenitor subpopulations may be an important root cause of MM relapse and contribute to 
the current failure to cure MM [Chng et al., 2014]; however, comprehensive data is lacking. 

 
 
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Although Xbp1s- MM progenitors appear PI insensitive, it is unknown whether these cells 
respond to or can survive treatments such as high-dose melphalan and ASCT; furthermore it is 
unknown whether or not they are fully malignant (genetically identical to the mature PCs that 
constitute the MM tumor bulk cells) or if they can produce MM relapse and disease in patients. 
The optimal means to target these cells is unknown, and it is unclear if they will respond to 
emerging immunotherapeutics (which are likely to become the next standard of care).  
 
To achieve deeper and more durable therapeutic responses for patients, another aim of this study 
is to leverage the recent identification of MM progenitor subpopulations to help guide the 
development of better therapeutic strategies that address residual disease in MM. The extent and 
characteristics of progenitor MRD in MM will be examined to determine which if any tumor 
subpopulations preferentially survive treatment and that should be better targeted. Treatments will 
be compared to determine if any have superior activity against specific tumor subpopulations. 
The mutational landscape of MM plasma cells and MM progenitors will be compared over 
longitudinally acquired serial samples from patients treated with standard MM therapies to 
determine if MM progenitor subpopulations possess or lack mutations identified in concurrent 
MM PC subpopulations, or if MM progenitor subpopulations contribute to later relapsed PC 
populations. This will help define the extent to which dynamic transitions occur between these 
tumor subpopulations and whether progenitor subpopulations contribute to evasion of standard 
therapy. As well, from this characterization of restricted antigen expression on MM progenitors, 
we aim to provide a basis for broader immunotherapeutic strategies in MM that may provide 
more durable responses against tumors that demonstrably contain marked intra-clonal functional 
and genetic diversity. Together, these studies will substantially clarify the roles of MM progenitor 
subpopulations in therapeutic evasion, relapse and tumor evolution and will provide a framework 
for targeting of these subpopulations in the clinic.  
 
3.0 
STUDY POPULATION 
This is a pan-Canadian prospective cohort study run through the University of New Brunswick 
with financial support from the Terry Fox Research Institute. The aim is to recruit 250 patients 
over the course of the five years of the study. 
 
3.1 
Eligibility Criteria 
 
Questions about eligibility criteria should be addressed prior to registration. For a patient to be 
eligible for admission to the study:  
 
• 
Age ≥  19 years; 
 
• 
Ability to give informed consent; 
 
• 
Diagnosed with active multiple myeloma (refer to Appendix I for IMWG definition); 
 
• 
Also enrolling in the CMM-DB project; and 
 
• 
Previously untreated and eligible for autologous stem-cell transplantation (ASCT).  
 

 
 
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Patients who are going to be treated on a clinical trial are also eligible to participate in this study 
if they meet the other eligibility criteria. 
 
3.2 
Informed Consent 
 
Patient consent must be appropriately obtained in accordance with applicable local and regulatory 
requirements. Each patient must sign a consent form prior to enrollment in the study to document 
their willingness to participate.  
 
4.0 
ENTRY AND REGISTRATION PROCEDURES 
 
All eligible patients enrolled in the study by the participating treatment centre will be assigned a 
serial number which must be used on all documentation and correspondence with the 
coordinating centre (University of New Brunswick). The following information will be required:  
• 
Study code (M4 XX.XX) 
• 
Informed consent version date, date signed by patient, name of person conducting consent 
discussion and date signed 
 
Note: The validity of study results depends on the authenticity of and the follow-up of all patients 
entered into the study. Under no circumstances, therefore, may an allocated patient’s data be 
withdrawn prior to final analysis, unless the participant withdraws from the study and requests 
that data collection/submission cease from the point in time of withdrawal. 
 
All eligible patients admitted to the study will be followed by the coordinating centre. It is the 
responsibility of the physician in charge to satisfy himself or herself that the patient is indeed 
eligible before requesting registration. 
 
 
 

 
 
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5.0 
PLAN FOR CLINICAL EVALUATION AND DATA COLLECTION  
 
M4 study data – i.e. clinical data, blood and bone marrow samples, lab test results, economic data 
and patient-reported outcomes – will be collected from all patients, and PET scan data will be 
collected on all patients at baseline and on approximately 80 (those in complete response (CR)) 
after 12 months of maintenance therapy (more detail is provided in Table 1).  BM for flow MRD 
will be collected at three time points only: baseline, 100 days post-ASCT and after 12 months of 
maintenance therapy. Clinical data will be collected via the CMM-DB Project, under a separate 
protocol and consent process. M4 data and CMM-DB data will be linked for subsequent analysis, 
with the remaining data and biospecimens collected in the present M4 study.  
 
Multiple myeloma diagnosed and patient consented 
↓ 
 
Treatment plan, baseline M4 data collection*  
↓ 
 
Baseline 18F-FDG-PET scan (all patients) 
↓ 
 
Initial therapy 
↓ 
 
M4 data collection 
↓ 
 
Stem cell mobilization and collection 
↓ 
 
Autologous stem cell transplantation (ASCT) 
↓ 
 
M4 data collection 100 days following ASCT*# 
↓ 
 
Maintenance therapy 
↓ 
 
M4 data collection* and 18F-FDG-PET scan (on 80 patients in CR)  
after 12 months of maintenance therapy  
↓ 
 
M4 data collection every 6 months  
until end of study, relapse or death 
 
*BM for flow MRD collected at this time point 
# A subset of up to 20 patients will have this assessment at 1-3 days post-transplant instead 
 

 
 
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Table 1. Schedule of Visits 
Research and Treatment Visits 
1 
2 
3 
4 
5 
6 
7 
8 
9+ 
R 
Before 
treatment 
begins: 
Patient 
and 
researcher discuss the study and sign informed 
consent. Patient is screened for inclusion or 
exclusion in study.  
X 
 
 
 
 
 
 
 
 
 
Data Collection for Research 
 
Start chemotherapy 
 
Stem cell transplant 
 
Maintenance therapy 
 
 
 
 
Blood collection~ 
X 
X 
X 
X 
X 
X 
X 
Bone marrow collection~ 
X^ 
X 
X^ 
X^ 
X 
X 
X 
PET/CT scan* 
X 
 
X 
 
 
 
Self-report quality of life questionnaires 
X 
X 
X 
X 
X 
X 
X 
Occupation Recording  
X 
 
 
 
 
 
 
Study nurse completes Resource Utilization 
Form  
X 
X 
X 
X 
X 
X 
X 
~In addition to amounts collected for clinical purposes. 
* All patients to receive a PET/CT at baseline; an additional 80 patients (those in CR) will also receive one after 12 months of 
maintenance therapy.  
^BM for flow MRD collected at this time point. 
Year 1 Visits: Prior to treatment (#1); Following chemotherapy (#3); Following stem cell transplant, most participants will undergo 
assessment at day 100 (±20 days), before starting maintenance therapy; up to 20 patients will be asked to undergo assessment instead at 1-
3 days post-transplant (#5). Year 2 Visits: After 12 months of maintenance therapy (#7), and 6 months after Visit #7 (#8). Years 3 and 
beyond: Every 6 months (#9+) until the study is completed, myeloma relapses, or death; R (Relapse): Additional visit will occur in case 
of relapse. 
 
 
 
 

 
 
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6.0 
CRITERIA FOR MEASUREMENT OF STUDY ENDPOINTS 
 
To assess the level of response in patients, the following guidelines from the International 
Myeloma Working Group will be used. It is expected that these tests form part of the standard of 
care for myeloma patients, but it is recognized that there are variations in local approaches to 
response assessment. The following table outlines the recommended standard of care tests for 
response evaluation. It is strongly recommended that this schedule of standard response 
evaluation be followed as closely as possible. The available data on standard response assessment 
will be captured on M4 study patients in the CMM-DB protocol in which all M4 patients are 
required to enroll, and will be used as part of the M4 analysis. However, in the end, the standard 
of care response evaluation for each patient is left to the discretion of the attending physician. 
Table 2. Required Baseline and Follow-Up Tests for Response Assessment [Kumar et al., 2016] 
 
Every response 
assessment time 
point 
If electrophoresis 
shows no 
measurable protein 
At 
suspected 
CR 
At suspected 
progression (clinical 
or biochemical) 
SPEP 
X 
◦◦ 
X 
X 
Serum immunofixation 
◦◦ 
X 
X 
X 
UPEP  
X 
◦◦ 
X 
X 
Urine immunofixation 
◦◦ 
X 
X 
◦◦ 
Serum FLC  
X 
◦◦ 
X 
X 
Bone marrow aspirate 
X 
◦◦ 
X 
X 
Plasmacytoma imaging 
 
 
 
 
Serum M-spike, urine M-spike, involved Ig 
FLC or bone marrow not meeting above 
criteria, but at least one lesion that has a 
single diameter of ≥2 cm 
X 
◦◦ 
X 
◦◦ 
Haemoglobin, serum calcium, creatinine  
X 
◦◦ 
◦◦ 
X 
CR = complete response. SPEP = serum protein electrophoresis. UPEP = urine protein electrophoresis. FLC = free light chain. 
IMWG = International Myeloma Working Group. X = test performed. ◦◦ = test not performed.  
 
 
 
 
 

 
 
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7.0 
STATISTICAL CONSIDERATIONS 
 
7.1  
Objectives and Design 
 
This is an investigator-initiated multicentre study assessing three techniques for the detection of 
multiple myeloma MRD. 
 
7.2  
Primary Endpoints and Analyses 
 
Our primary comparison is the sensitivity of MFC versus IgS in patients who meet the 
conventional definition of complete remission post-treatment. We expect ~50% of patients, or 
125 patients, to be eligible for this comparison.  
 
7.3 
Sample Size and Power  
 
Based on prior studies we expect that approximately 60% (75 of 125) of patients will show 
evidence of MRD by MFC. We will then have 80% power with a 1-sided alpha of 0.05 to detect 
an increase in sensitivity of 11% for IgS compared to MFC. 
 
7.4  
Secondary Endpoints and Analyses 
 
• 
Comparisons of the sensitivity of MFC and IgS with PET scans to detect MRD 
• 
The prognostic significance of MRD assessment on PFS and OS 
• 
The economic impact of MRD testing 
• 
QOL in patients undergoing MRD testing 
• 
Exploration of leading edge methods of myeloma characterization and monitoring 
o Prognostic significance of ctDNA profiles 
o Sensitivity and specificity of bioassays of drug resistance 
o Characterization of myeloma progenitor populations that persist in the MRD state 
 
For further details about the planned laboratory, clinical, economic, quality of life and statistical 
analyses, please refer to the R&D Plan for this study that was approved by the Terry Fox 
Research Institute Executive and an International Review Committee. The R&D Plan is to be 
submitted with this protocol to participating sites for the information of those conducting local 
institutional review, including the Research Ethics Board. 
 
 

 
 
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8.0 
ETHICAL, REGULATORY AND ADMINISTRATIVE ISSUES 
 
8.1 
Inclusivity in Research 
 
This study does not exclude individuals from participation on the basis of attributes such as 
culture, religion, race, national or ethnic origin, colour, mental or physical disability (except 
incapacity), sexual orientation, sex/gender, occupation, ethnicity, income, or criminal record, 
unless there is a valid reason (i.e. safety) for the exclusion.  
 
In accordance with the Declaration of Helsinki and the Tri-Council Policy Statement (TCPS), 
vulnerable persons or groups will not be automatically excluded from a clinical study (except for 
incompetent persons) if participation in the study may benefit the patient or a group to which the 
person belongs. However, extra protections may be necessary for vulnerable persons or groups. It 
is the responsibility of the local investigator and research ethics board (REB) to ensure that 
appropriate mechanisms are in place to protect vulnerable persons/groups. In accordance with 
TCPS, researchers and REBs should provide special protections for those who are vulnerable to 
abuse, exploitation or discrimination. As vulnerable populations may be susceptible to coercion 
or undue influence, it is especially important that informed consent be obtained appropriately.  
 
Centres are expected to ensure compliance with local REB or institutional policy regarding 
participation of vulnerable persons/groups. It is the centre’s responsibility to ensure compliance 
with all local SOPs.  
 
Persons who cannot give informed consent (i.e., mentally incompetent persons, or those 
physically incapacitated, such as comatose persons) are not to be recruited into this study. It is the 
responsibility of the local investigator to determine the subject’s competency, in accordance with 
applicable local policies and in conjunction with the local REB (if applicable).  
 
8.2 
Obtaining Informed Consent 
 
It is expected that consent will be appropriately obtained for each participant/potential participant 
in this study, in accordance with ICH-GCP section 4.8. The centre is responsible for ensuring that 
all local policies are followed. 
 
Additionally, in accordance with GCP 4.8.2, this study may require that participants/potential 
participants be informed of any new information may impact a participant’s/potential 
participant’s willingness to participate in the study.  
 
Based upon applicable guidelines and regulations (Declaration of Helsinki, ICH-GCP), a 
participating investigator (as defined on the participants list) is ultimately responsible, in terms of 
liability and compliance, for ensuring informed consent has been appropriately obtained. It is 
recognized that in many centres other personnel (as designated on the participants list) also play 
an important role in this process. In accordance with GCP 4.8.5, it is acceptable for the Qualified 
Investigator to delegate the responsibility for conducting the consent discussion. 
 
It is required that each participant sign a consent form prior to their enrollment in the study to 
document his/her willingness to take part. Written informed consent will be obtained for all study 
procedures, the planned analyses of the biospecimens and data, linkage to clinical outcomes data 

 
 
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in the CMM-DB project, and long-term banking of biospecimens and data for future research. 
Ongoing REB approval will be maintained for curating the M4 biobank and associated data, and 
future REB approval will be required for any new research to be conducted using the M4 biobank 
and data. It may also be required, as indicated above, that participants/potential participants be 
informed of new information if it becomes available during the course of the study. In 
conjunction with GCP 4.8.2, the communication of this information should be documented. 
 
The use of translators is allowed in obtaining informed consent. Provision of translators is the 
responsibility of the local centre. Centres should follow applicable local policies when procuring 
or using a translator for the purpose of obtaining informed consent to participate in a clinical 
study.  
 
In accordance with ICH-GCP 4.8.9, if a subject is unable to read then informed consent may be 
obtained by having the consent form read and explained to the subject.  
 
8.3 
Discontinuation of the Study 
 
If this study is discontinued for any reason all centres will be notified in writing of the 
discontinuance and the reason(s) why. If the reason(s) for discontinuance involve any potential 
risks to the health of patients participating on the study or other persons, this information will be 
provided to centres as well. 
 
If this study is discontinued at any time by the centre (prior to closure of the study by the 
coordinating centre), it is the responsibility of the qualified investigator to notify the coordinating 
centre of the discontinuation and the reason(s) why.  
 
Whether the study is discontinued by the coordinating centre or locally by the centre, it is the 
responsibility of the qualified investigator to notify the local Research Ethics Board and all 
clinical study subjects of the discontinuance and any potential risks to the subjects or other 
persons. 
 
8.4  
Retention of Patient Records and Study Files 
 
All essential documents must be maintained in accordance with ICH-GCP.  
 
 

 
 
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9.0 
REFERENCES  
 
Avet-Loiseau H, Corre J, Lauwers-Cances V, Chretien M, Robillard N, Leleu X, et al. 191 
Evaluation of Minimal Residual Disease (MRD) By Next Generation Sequencing (NGS) Is 
Highly Predictive of Progression Free Survival in the IFM/DFCI 2009 Study. 2015. 
 
Benboubker L, Dimopoulos MA, Dispenzieri A, Catalano J, Belch AR, Cavo M, et al. 
Lenalidomide and dexamethasone in transplant-ineligible patients with myeloma. N Engl J Med 
2014 09/04;371(10):906- 917.  
 
Bolli N, Avet-Loiseau H, Wedge DC, Van Loo P, Alexandrov LB, Martincorena I, et al.  
Heterogeneity of genomic evolution and mutational profiles in multiple myeloma. Nat Commun 
2014;5:2997-2997. 
 
Chapman MA, Lawrence MS, Keats JJ, Cibulskis K, Sougnez C, Schinzel AC, et al. Initial 
genome sequencing and analysis of multiple myeloma. Nature 2011 03/24;471(7339):467-472. 
 
Chng WJ, Dispenzieri A, Chim C, Fonseca R, Goldschmidt H, Lentzsch S, et al. IMWG 
consensus on risk stratification in multiple myeloma. Leukemia 2014 02;28(2):269-277. 
 
Cristofanilli M, Budd GT, Ellis MJ, Stopeck A, Matera J, Miller MC, et al. Circulating tumor 
cells, disease progression, and survival in metastatic breast cancer. N Engl J Med 2004 
08/19;351(8):781-791. 
 
González D, van dB, García-Sanz R, Fenton JA, Langerak AW, González M, et al. 
Immunoglobulin gene rearrangements and the pathogenesis of multiple myeloma. Blood 2007 
11/01;110(9):3112-3121. 
  
Kapoor P, Kumar SK, Dispenzieri A, Lacy MQ, Buadi F, Dingli D, et al. Importance of achieving 
stringent complete response after autologous stem-cell transplantation in multiple myeloma. J 
Clin Oncol 2013 12/20;31(36):4529-4535. 
 
Korde N, Roschewski M, Zingone A, Kwok M, Manasanch EE, Bhutani M, et al. Treatment  
With Carfilzomib-Lenalidomide-Dexamethasone With Lenalidomide Extension in Patients With  
Smoldering or Newly Diagnosed Multiple Myeloma. JAMA Oncol 2015 09;1(6):746-754.  
 
Kumar S, et al. International Myeloma Working Group consensus criteria for response and 
minimal residual disease assessment in multiple myeloma. Lanc Onc 2016; 17(8): e328-e346. 
 
Leung-Hagesteijn C, Erdmann N, Cheung G, Keats JJ, Stewart AK, Reece DE, et al. Xbp1s-
Negative Tumor B Cells and Pre-Plasmablasts Mediate Therapeutic Proteasome Inhibitor 
Resistance in Multiple Myeloma. Cancer Cell (Science Direct) 2013 09/09;24(3):289-304. 
 
Mailankody S, Korde N, Lesokhin AM, Lendvai N, Hassoun H, Stetler-Stevenson M, et al. 
Minimal residual disease in multiple myeloma: bringing the bench to the bedside. Nat Rev Clin 
Oncol 2015 05;12(5):286-295.  
 

 
 
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Martinez-Lopez J, Lahuerta JJ, Pepin F, González M, Barrio S, Ayala R, et al. Prognostic value 
of deep sequencing method for minimal residual disease detection in multiple myeloma. Blood 
2014 5/15;123(20):3073-3079 
 
Matsui W, Wang Q, Barber JP, Brennan S, Smith BD, Borrello I, et al. Clonogenic multiple 
myeloma progenitors, stem cell properties, and drug resistance. Cancer Res 2008 
01/01;68(1):190-197.  
 
Moreau P, Attal M, Karlin L, Garderet L, Facon T, Macro M, et al. 395 Prospective Evaluation of 
MRI and PET-CT at Diagnosis and before Maintenance Therapy in Symptomatic Patients with 
Multiple Myeloma Included in the IFM/DFCI 2009 Study. 2015. 
 
Nygaard AD, Garm Spindler K, Pallisgaard N, Andersen RF, Jakobsen A. The prognostic value 
of KRAS mutated plasma DNA in advanced non-small cell lung cancer. Lung Cancer 2013 
03;79(3):312-317. 
 
Paiva B, Vidriales M, Cerveró J, Mateo G, Pérez J,J., Montalbán M,A., et al. Multiparameter flow 
cytometric remission is the most relevant prognostic factor for multiple myeloma patients who 
undergo autologous stem cell transplantation. Blood 2008 11/15;112(10):4017-4023. 
 
Rajkumar SV, Harousseau J, Durie B, Anderson KC, Dimopoulos M, Kyle R, et al. International 
Myeloma Working Group updated criteria for the diagnosis of multiple myeloma.  The Lancet 
Oncology 2014; 15(12): e538-48. 
Rawstron AC, Child JA, de Tute R,M., Davies FE, Gregory WM, Bell SE, et al. Minimal residual 
disease assessed by multiparameter flow cytometry in multiple myeloma: impact on outcome in 
the Medical Research Council Myeloma IX Study. J Clin Oncol 2013 07/10;31(20):2540-2547. 
 
Rawstron AC, Gregory WM, de Tute R,M., Davies FE, Bell SE, Drayson MT, et al. Minimal 
residual disease in myeloma by flow cytometry: independent prediction of survival benefit per 
log reduction. Blood 2015 03/19;125(12):1932-1935. 
  
Reinert T, Schøler L,V., Thomsen R, Tobiasen H, Vang S, Nordentoft I, et al. Analysis of 
circulating tumour DNA to monitor disease burden following colorectal cancer surgery. Gut 2015 
02/04. 
 
Roschewski M, Dunleavy K, Pittaluga S, Moorhead M, Pepin F, Kong K, et al. Circulating 
tumour DNA and CT monitoring in patients with untreated diffuse large B-cell lymphoma: a 
correlative biomarker study. Lancet Oncol 2015 05;16(5):541-549. 
 
Schinke C, Deshpande S, Mitchell A, Faham M, Patel P, Thanendrarajan S, et al. 2979 Impact of 
Minimal Residual Disease in High and Standard Risk Multiple Myeloma. 2015.  
 
Schwarzenbach H, Eichelser C, Kropidlowski J, Janni W, Rack B, Pantel K. Loss of 
heterozygosity at tumor suppressor genes detectable on fractionated circulating cell-free tumor 
DNA as indicator of breast cancer progression. Clin Cancer Res 2012 10/15;18(20):5719-5730. 
  
Schwarzenbach H, Hoon DSB, Pantel K. Cell-free nucleic acids as biomarkers in cancer patients. 
Nat Rev Cancer 2011 06;11(6):426-437. 

 
 
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Silva JM, Silva J, Sanchez A, Garcia JM, Dominguez G, Provencio M, et al. Tumor DNA in 
plasma at diagnosis of breast cancer patients is a valuable predictor of disease-free survival. Clin 
Cancer Res 2002 12;8(12):3761-3766.  
 
Vij R, Mazumder A, Klinger M, O'Dea D, Paasch J, Martin T, et al. Deep sequencing reveals 
myeloma cells in peripheral blood in majority of multiple myeloma patients. Clin Lymphoma 
Myeloma Leuk 2014 04;14(2):131-139.e1.  
 
Zamagni E, Nanni C, Mancuso K, Tacchetti P, Pezzi A, Pantani L, et al. PET/CT Improves the 
Definition of Complete Response and Allows to Detect Otherwise Unidentifiable Skeletal 
Progression in Multiple Myeloma. Clin Cancer Res 2015 10/01;21(19):4384-4390.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
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APPENDIX I – DEFINITION OF MULTIPLE MYELOMA 
Clonal bone marrow plasma cells ≥10% OR biopsy-proven bony or extramedullary plasmacytoma AND 
any one or more of the following CRAB features and myeloma-defining events (MDEs): 
 
1. Evidence of end organ damage attributable to the underlying plasma cell proliferative disorder, 
specifically: 
 
a. Hypercalcemia 
Serum calcium >0.25 mmol/L (>1mg/dL) higher than upper limit of normal or 
>2.75 mmol/L (>11mg/dL) 
 
b. Renal Insufficiency  
Creatinine clearance <40 mL/min or serum creatinine >177µmol/L (>2mg/dL) 
 
c. Anemia  
Hemoglobin >20g/L below lowest limit of normal, or <100g/L 
 
d. Bone lesions 
One or more osteolytic lesion on skeletal radiography, CT, or PET/CT. If bone marrow has 
<10% clonal plasma cells, more than one bone lesion is required to distinguish from solitary 
plasmacytoma with minimal marrow involvement 
 
e.    Any one or more of the following biomarkers of malignancy (MDEs): 
 
- 
60% or greater clonal plasma cells on bone marrow examination 
- 
Serum involved / uninvolved free light chain ratio of 100 or greater, provided the 
absolute level of the involved light chain is at least 100mg/L 
- 
More than one focal lesion on MRI that is at least 5mm or greater in size. 
 
 
 

 
 
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APPENDIX II: LAY SUMMARY 
 
Multiple myeloma (MM) is a deadly cancer of the bone marrow that is challenging to manage and treat: 
the drugs that are currently available attack the cancer in the same way for everyone, but each patient has 
different types of MM cancer cells and different family traits that predict better or worse outcomes. As 
well, the ways in which we test to see if the cancer is in remission are not very good at detecting small 
numbers of cancer cells still in the bone marrow after treatment – and which will,  sooner or later cause 
the patient to get sick again. So, the goal of our research is to improve MM patients’ survival and quality 
of life over time, by finding better ways of a) characterizing each patient’s experience with the disease, 
and b) identifying and tracking the small numbers of cells that remain after treatment.   
 
Our plan is to track 250 patients across Canada over time, who are getting treatment for multiple 
myeloma. While they are getting treatment, our research will evaluate samples of their blood and bone 
marrow with newer, more precise laboratory tests. We will also ask patients to take part in two scans of 
their bodies during their treatment. We think that these tests can help doctors make better treatment 
recommendations to patients.  
 
We will look at whether one test is better than another, or if we need to use a combination of these tests to 
have the best information possible to make treatment decisions. At the same time, we will also be looking 
into how and why some patients’ cancer becomes resistant to the treatments over time, and how myeloma 
cells are able to start growing again after treatment. Our team will also collect information on how each 
patient’s health and quality of life changes during and after treatment, and what are the associated costs 
with these new approaches – to both the healthcare system overall, and to patients.  
 
Once we have completed our five-year research program, we hope to have created a proven and 
affordable process of combining these new laboratory tests with our current clinical approach, to create 
new options to evaluate and treat multiple myeloma. 
 
It is our goal that this research will make a difference, right away and across the world, in how doctors 
treat multiple myeloma, in how it is studied by scientists, and in how patients advocate for their own 
healthcare. 
 
 

ENGLISH 
 
21 
 
APPENDIX III – CONTACT INFORMATION FOR COORDINATING CENTRE AND SITES 
 
COORDINATING CENTRE 
 
University of New Brunswick (Saint John) 
Dr. Tony Reiman (anthony.reiman@horizonnb.ca; 506-648-6885) 
Dr. Alli Murugesan (Alli.Murugesan@unb.ca) 
 
 
PARTICIPATING SITES 
 
Saint John Regional Hospital 
Dr. Tony Reiman (anthony.reiman@horizonnb.ca; 506-648-6885) 
 
QEII Health Sciences Centre, VG Site 
Dr. Darrell White (darrell.white@nshealth.ca; 902-473-4642)  
 
Hôpital Maisonneuve-Rosemont 
Dr. Jean Roy (jroy.hmr@ssss.gouv.qc.ca; 514-252-3400 x3404) 
 
McGill University Health Centre 
Dr. Michael Sebag (michael.sebag@mcgill.ca; 514-843-1558) 
 
The Ottawa Hospital 
Dr. Arleigh McCurdy (amccurdy@toh.ca; 613 737 8899 x71281) 
 
Sunnybrook Odette Cancer Centre 
Dr. Matthew Cheung (matthew.cheung@sunnybrook.ca; 416-480-6100 x7672) 
 
UHN Princess Margaret Cancer Centre  
Dr. Donna Reece (donna.reece@uhn.ca; 416-946-2824) 
 
CancerCareManitoba 
Dr. Rami Kotb (rkotb@cancercare.mb.ca) 
 
Cross Cancer Institute 
Dr. Christopher Venner (christopherPaul.venner@albertahealthservices.ca) 
 
University of Calgary 
Dr. Nizar Bahlis (nbahlis@ucalgary.ca; 403-944-1880) 
 
Leukemia/Bone Marrow Transplant Program of British Columbia 
Dr. Kevin W. Song (ksong@bccancer.bc.ca) 
Dr. Heather Sutherland (hsutherl@bccancer.bc.ca)