Bispecifics' Step-Up Dosing Puts Pressure on Community Resources

Delivering bispecific therapies comes with a hidden operational cost burden that community oncology practices are ill-equipped to absorb, according to Lekan Ajayi, PharmD, chief operating officer of Highlands Oncology Group and moderator of The American Journal of Managed Care^®’s (AJMC^®) Bispecifics Network for 2026.

What Step-Up Dosing Demands From Practices

Step-up dosing is a regimen in which a drug is administered at incrementally increasing doses over a defined period, and it is a standard feature of many bispecific antibody therapies. While the approach is designed to reduce adverse events such as cytokine release syndrome, it carries significant logistical and financial implications for the practices tasked with delivering it.

"In community oncology currently, and in oncology in general, those are things that are not really reimbursed for," he said. "It's a substantial cost to the practice to be able to deliver these therapies and step up their dosing over time."

That cost is not merely financial. Step-up dosing is time-intensive for clinical staff, requiring repeated patient visits and close monitoring across what can be an extended initiation period—all of which draws on staffing resources that practices may not have the capacity to spare.

Compounding the resource strain is the cross-site coordination that bispecific initiation often demands. Many bispecific regimens require that early doses given during the step-up phase be administered in a hospital setting, where the infrastructure to manage high-acuity adverse events is available. Once the patient is past the highest-risk window, care may then transition to a community or outpatient setting.

That handoff between sites is logistically complex. Ajayi noted that the level of acuity involved in hospital-based initiation adds another layer of resource intensity, and that getting patients to the right site at the right time requires communication and coordination systems that are still being developed.

Looking Ahead for the Bispecifics Network

As part of AJMC's Bispecifics Network, Ajayi will be fielding audience questions on these and other practical challenges facing oncology practices integrating bispecific therapies into their care models. The questions of reimbursement adequacy, site-of-care selection, and care coordination will be central themes—issues that, Ajayi suggested, the field will need to "iron out" as adoption of bispecifics continues to grow across tumor types and practice settings.