Building strong support systems from both clinical and personal perspectives can drive optimal patient outcomes.
Jeffrey Matous, MD: Let’s fast-forward a little. We’re in the future, where we’re a little more comfortable doing a lot of these treatments on an outpatient basis. Who needs to be educated? Presumably, we’ve done the REMS [Risk Evaluation and Mitigation Strategy] program. What other parts of the health care system—emergency department, intensive care unit [ICU]—need to be educated?
Zahra Mahmoudjafari, PharmD, MBA, BCOP, FHOPA: I’ll take a step back even further and say the caregiver. They take on quite a bit of responsibility. We do a lot of our transplants outpatient, so caregivers take on such a burden of responsibility. And they don’t take it lightly; they take it very seriously. They make sure they’re properly educated and have the tools and know whom to contact should things go awry. First and foremost, the patients and the caregivers need to be educated. So do the ICU team, the emergency department, the navigators, and all the individuals who may come into exposure with these patients, but the first group would be the caregivers.
Kirollos Hanna, PharmD, BCPS, BCOP, FACCC: Sometimeseven lab. We’re always having a conversation about who handles CAR [chimeric antigen receptor] T cells. Is it a pharmacy thing? Does pharmacy label, administer, and dispense it? Is it the lab or the blood bank? In some systems, that’s another barrier to work through.
Jeffrey Matous, MD: We’re seeing more patients on commercial teclistamab. Has anyone run into difficulty finding room for them at your institutions? Does that involve the normal wards?
Beth Faiman, PhD, MSN, APN-BC: We have to put in a bed reservation and get insurance approval and supportive care approval, and that tends to take about 10 days. If a patient really needs to be admitted for teclistamab, we might be able to do it within a couple of days. But we’re asked to wait 10 days. We have a lymphoma-myeloma service—the group that takes our patients on teclistamab—and it’s staffed by advanced practitioners, PAs [physician assistants], and NPs [nurse practitioners] with a staff physician overseeing. We have a large service, with about 35 patients. Then we have to find the bed throughout the hospital. We have a large hospital system, but they’re not always going to a chemotherapy floor. We have a chemotherapy certification. This isn’t chemotherapy; it’s immunotherapy. But it’s based on how it’s given. We have to educate everybody who might have touch points, so we have a nurse navigator who’s an expert in oncology who will float to that floor and possibly give the drug. But some patients need to be monitored.
It’s hard to educate these patients. They’re used to getting treatments outpatient. Or they get daratumumab or carfilzomib or take pills at home. Now they have to be admitted, and they haven’t been admitted since transplant. They say “I’m going to get sick and get a fever.” You have 2 groups: patients who are willing to accept hospital admission to take of their cancer, and the other group that doesn’t want to go to the hospital for 7 to 9 days and get sick. Quality of life is more important. We try to underscore that the studies show your quality of life will be better after your disease is in remission on these drugs. But some patients don’t want to take that drug.
Jeffrey Matous, MD: Did anybody see the paper presented at ASH [American Society of Hematology Annual Meeting] last year about premedicating with tocilizumab prior to a different bispecific known as cevostamab?
Beth Faiman, PhD, MSN, APN-BC: Was that Tom Martin? Who was it?
Jeffrey Matous, MD: That was Suzanne Trudel.
Beth Faiman, PhD, MSN, APN-BC: Yes.
Jeffrey Matous, MD: This is a question that’s being addressed in the MajesTEC-1 trial, which is still going on by the way.
Beth Faiman, PhD, MSN, APN-BC: Yes.
Jeffrey Matous, MD: MajesTEC-1 is still asking a number of questions: fixed dosing, the interval between treatments, manufacturing questions. There are a lot of things going on. Like most things we use in life, they get approved and then we figure out how to use them. That’s what happens.
Beth Faiman, PhD, MSN, APN-BC: It wasn’t randomized. Was it phase 2?
Jeffrey Matous, MD: Totally, yes. They see only that. They used cevostamab, which is an FCRH5 bispecific antibody, and they gave a single dose of tocilizumab prior to the first step-up doses of cevostamab. They showed a reduction in CRS [cytokine release syndrome], but they didn’t show complete elimination of CRS. Still, a fair percentage of patients who received tocilizumab premedication received tocilizumab again when they got CRS. This question is going to be answered. When I talk to our community and referral doctors, there’s a tremendous interest in whether to do this more successfully as an outpatient with tocilizumab or some premedication schedule, similar to what the lymphoma oncologists are doing with steroid premedicationto see if that might make this much more feasible on an outpatient basis.
Let me throw a question out to the panel because it’s time to do that. Let’s say I have both of these tools in my toolbox: T-cell redirecting antibodies and CAR T cells. Let’s say that I don’t have to ration my CAR T-cell therapy. They’re readily available. Which 1? Is there a right 1? Is there a sequence?
Kirollos Hanna, PharmD, BCPS, BCOP, FACCC: My thought that I’ll throw out there is the patient convenience aspect. I’m putting my pharmacist hat on right now. With CAR T, it’s 1 and done, and then you watch them. With bispecifics, you have 1 of your first bispecifics that’s not in myeloma; that’s a continuous infusion. You have your myeloma bispecific; that’s weekly. From a convenience perspective, could we give these patients 10 or 11 months off treatment? The cost is a different conversation as well. But teclistamab comes with a cost.
Beth Faiman, PhD, MSN, APN-BC: How much is daratumumab ongoing?
Kirollos Hanna, PharmD, BCPS, BCOP, FACCC: Correct. Or a quadruplet.
Zahra Mahmoudjafari, PharmD, MBA, BCOP, FHOPA: This question is going to be answered because CAR T cells are moving into earlier lines of care. Let’s say we’re 5 years in the future, give or take, where bispecifics have moved into earlier lines of care. At this point, we’re sure that we’ll see them in earlier lines of therapy. Also, these centers have access to CAR T-cell therapies. All things equal, we’re going to go to CAR T first and be as aggressive as possible for as long as possible. Then the sequence should be bispecifics afterward because it’s not necessarily going to be a prolonged duration of response.
That’s the million-dollar question: how do you sequence these? We have a great repertoire of options. Looking at high-risk patients vs certain molecular genetic abnormalities. All those things need to come into play. We need head-to-head trials. We need long-term data. We need better CRS management. There’s so much happening in the setting of multiple myeloma. It’s an exciting time. But all things equal, knowing that it’s going to be moving in earlier lines of therapy, I’d say CAR-T.
Transcript edited for clarity.