Expanding Community Access to CAR T, Bispecific Therapies in Multiple Myeloma: Peter Forsberg, MD

Novel immunotherapies such as chimeric antigen receptor (CAR) T-cell therapy and bispecific T-cell engagers have transformed the treatment landscape for multiple myeloma, but expanding patient access will require health systems to adapt as these therapies move into earlier lines of care.

During the recent Denver Regional Institute for Value-Based Medicine^® event, Peter Forsberg, MD, a hematologist-oncologist at the Colorado Blood Cancer Institute, discussed the operational, reimbursement, and care delivery challenges associated with bringing these therapies to more patients. In an interview with The American Journal of Managed Care^® (AJMC^®), he emphasized the importance of strengthening collaboration between academic and community oncology practices while developing health system infrastructure to support equitable access to advanced therapies.

In this Q&A, Forsberg discusses referral pathways, payer barriers, community-based clinical trials, and how value-based care models can better evaluate high-cost immunotherapies for multiple myeloma.

This transcript was lightly edited for clarity.

AJMC: Many patients with multiple myeloma receive care in community oncology settings before being referred to specialized centers. Where do you see the biggest gaps in referral pathways, and how can academic and community practices work together to streamline access to advanced cellular therapies?

Forsberg: We know that with multiple myeloma, about 80% of patient care happens in community settings. The large majority of patients with myeloma are treated in the community, and those are the patients who need access to these treatments. These treatments have been shown to be superior in terms of progression-free and overall survival compared with the classic combinations that have historically been easier to access.

We really need to find improved ways to provide access for the broadest number of patients. Right now, we have good pathways, but they could undoubtedly be much better. They leave certain patients behind—those who have the toughest time getting to an academic center and those with the greatest vulnerability in terms of economics, social circumstances, age, or caregiver support. We're leaving our most vulnerable patients behind, and I think we need fundamental changes in that regard.

Some of that involves system improvements, but it also requires us to find ways to bring these treatments to where patients live. I think we can only improve the pathways and the connections between community and academic oncologists to a certain degree. We really need to build on that relationship—not just to help patients access treatment at academic centers but also to allow academic providers to give guidance so patient management can happen closer to home. We need supportive relationships that help facilitate bringing treatments like bispecific T-cell engager therapies into community clinics.

I truly think we can't reach the patients who need these therapies at the scale we need until we democratize these treatments and make them available in any center where patients are receiving care. That's the fundamental change we need, more than simply improving referral pathways.

AJMC: The growing number of treatment options has increased the complexity of payer coverage and reimbursement. Which managed care barriers most frequently delay access to novel myeloma therapies, and what policy changes would have the greatest impact on improving timely treatment?

Forsberg: Access to treatments from a managed care and payer approval perspective is complex. I think part of it is made more complex in myeloma because treatment progress is happening so quickly. Every 6 months, there's a shakeup, and a new treatment becomes the standard of care in a new setting. Sometimes, that's creating a degree of whiplash that coverage is having a hard time keeping up with.

I do think it requires advocacy from myeloma specialists and patients to ensure that treatments being validated in new settings are made available and accessible in those settings.

Beyond that, there are additional tools that are really necessary for these new treatments, like supportive care approaches, that are sometimes falling through the gaps. Those are almost as critical as the treatments themselves. We need greater recognition of the breadth of care that comes along with these new therapies, as well as accelerated routes to access them.

I think that's where we're still running into hurdles and barriers. As new treatments become the standard of care, coverage sometimes lags behind. Recognizing that these complex supportive care approaches are necessary to make sure the new treatments are administered safely and effectively is sometimes not being emphasized to the degree that it needs to be.

It requires continued stringency in making sure those necessary approaches are adhered to, both from a guideline-building perspective and in finding ways to streamline providers getting access to care for their patients. We know the health system is complex in those ways.

AJMC: As principal investigator on multiple clinical trials, what opportunities do you see to expand trial participation for patients with plasma cell disorders who may not live near major academic centers?

Forsberg: Access to clinical trials in community settings is something I'm particularly passionate about. I'm a researcher as part of a network called the Sarah Cannon Research Institute, which is a community-based research organization. We work hard to bring trials directly into community clinics to give patients access to novel and advanced treatments where they live. Many patients can't travel to academic centers, and these treatments often need to be administered repeatedly.

We need to find ways to do that. Some of it may involve trial designs that are geared toward community-based access, but I believe a lot of it comes down to emphasizing community-based clinical trials—trials that are done in community settings.

Sometimes that means we can answer questions that can only be answered in community-based settings while also generating data that directly informs community-based utilization. There are different novel approaches, but being very intentional about developing trials that incorporate community sites is a key component of not just making trials more accessible but also asking questions in the settings where these treatments will ultimately be administered, rather than only in highly specialized academic centers.

AJMC: From a value-based care perspective, what metrics should health systems and payers prioritize when evaluating the long-term impact of high-cost therapies like CAR T and bispecific antibodies beyond traditional clinical response rates?

Forsberg: I think this is an area that's been really dynamic, particularly because, in myeloma, these new treatment approaches—CAR T and bispecifics—are increasingly becoming fixed-duration therapies.

In the past, our treatments in myeloma were often indefinite. People would receive years of monoclonal antibody or oral targeted therapies. With CAR T, especially, and increasingly with bispecific T-cell engagers, we're considering therapies that are given either one time or over a fixed period and can often lead to remissions that stretch out for many years afterward. They can also prevent the need for expensive subsequent therapies over prolonged periods of time.

I think we need to develop metrics that evaluate the duration of therapy delivered over a short intervention period as a way to inform the value of our newer myeloma treatments. The race is on to compress that treatment interval more and more. That's the new frontier for us: what's the shortest amount of time we really need to give treatment to achieve the longest-term benefit?

With that, we need support from health systems to recognize the value of those approaches, even if the treatments are expensive over a short period of time.