Access, Logistics Shape Multiple Myeloma Immunotherapy Decisions

The choice between chimeric antigen receptor (CAR) T-cell therapy and bispecific antibody combinations for patients with multiple myeloma often comes down to logistics as much as clinical fit, Amandeep Godara, MBBS, explained in part 2 of an interview at the recent Institute for Value-Based Medicine® event in Salt Lake City, Utah. He continued by describing the challenges that arise when a rural community oncologist identifies patients eligible for immunotherapies.

Godara said his team at Huntsman Cancer Institute operates from the assumption that any patient referred for CAR T-cell therapy or bispecific antibody initiation needs the treatment urgently. Whenever possible, they try to engage with patients even earlier, at the first signs of biochemical progression, or as soon as a new line of therapy begins that is expected to produce only a brief response, so that conversations about efficacy, toxicity, and treatment preference can happen well before a crisis point.

However, Godara highlighted that several factors routinely slow the pathway from referral to treatment. Whether the therapy is needed immediately or is more of a future consideration is one factor that determines the pace, he noted.

Distance is another, as many patients cannot travel hours to receive treatment, and doing so risks losing critical time for patients who may need treatment urgently. To address this, Godara said he and other clinicians at Huntsman Cancer Institute obtained medical licenses in neighboring states, shifting much of the initial decision-making conversation to virtual visits, allowing patients to be evaluated without an in-person clinic trip.

Caregiver access is also a persistent obstacle, according to Godara. Both CAR T-cell therapy and bispecific antibody treatment require a caregiver to be present for at least the initial treatment period. Many patients, however, lack one readily available because caregivers are often occupied with work or their own responsibilities.

"That can stall the pathway to these CAR T-cell therapies or bispecific antibodies," Godara said.

Insurance requirements add a further layer of complexity, he added. Some payers favor use of a bispecific antibody at first relapse over CAR T-cell therapy, which can complicate the decision-making process.

Godara concluded that these combined disease- and patient-level factors frequently determine how quickly or slowly an eligible patient moves from referral to treatment initiation.