Hybrid, Outpatient, Network-Based: Bispecific Programs Take Shape Differently

Bispecific antibody programs are taking shape across community oncology in a wide variety of configurations, including hybrid academic-community systems, fully outpatient independent practices, and network-affiliated sites. Each model directly reflects the local resources, geography, and patient populations that practices serve, according to participants of The Bispecifics Network roundtable discussion.

The panel was led by Zahra Mahmoudjafari, PharmD, BCOP, director of pharmacy, advanced therapeutics, University of Kansas Health System (KU); Ralph Boccia, MD, hematologist-oncologist, Center for Cancer and Blood Disorders, an American Oncology Network (AON) practice; and Lekan Ajayi, PharmD, chief operating officer, Highlands Oncology Group.

How Programs Are Structuring Bispecific Delivery

At KU, a hybrid academic hub with community satellites spanning Kansas and Missouri, a dedicated interdisciplinary team that is anchored in the division of hematologic malignancies and cellular therapeutics oversees both hematologic and solid tumor bispecifics, with tarlatamab step-up dosing managed by the chimeric antigen receptor T-cell therapy team, Mahmoudjafari explained. The model has enabled outpatient step-up dosing for most patients, though a large catchment area introduces case-by-case variability.

Geographic considerations vary widely by region. While Mahmoudjafari noted that patients in KU's immediate footprint are typically within 30 to 45 minutes of a site, interactive chat feedback from the broader roundtable audience revealed that many community programs enforce strict protocol-driven limits, requiring patients to live within 30 miles or an hour of the emergency department to qualify for outpatient initiation.

Operating across 2 states also means navigating 2 distinct sets of pharmacy regulations, an administrative layer that adds complexity to an already intricate care model. Shared algorithms and policies across the health system have helped standardize care at community satellites, even those outside the KU system that the academic hub supports regionally. The health system provides 24/7 coverage and direct admission capability given its scale, a resource not every community partner can replicate.

Boccia's AON-affiliated practice operates a fully outpatient model, treating 2 to 3 bispecific patients per week internally across tumor types, with 12 providers on staff. The practice designates a dedicated T-cell–engaging team (2 physicians and 2 nurse practitioners) as the exclusive handlers of bispecific patients from initial referral through step-up dosing. Patients are only admitted to the hospital for grade 3 or 4 toxicity; lower-grade events are managed by bringing the patient back into the clinic for tocilizumab, intravenous fluids, and supportive care.

"Community is capable of doing these bispecifics in every practice in this country," Boccia said, emphasizing that the framework is replicable when practices invest in the right infrastructure.

The practice's affiliated hospital, a Johns Hopkins-owned community facility, provides both inpatient and outpatient support, though the clinic itself does not operate on weekends.

Highlands Oncology built its program with a single provider leading a cohort of 16 medical oncologists, supported by a dedicated advanced practice provider who manages all new patient consults. Once patients reach maintenance dosing, they transition back to their primary oncology team. The practice sees 2 to 3 bispecific patients weekly and performs all step-up dosing outpatient, actively discouraging emergency department use. Saturday clinic availability has been a differentiating feature, helping the practice accommodate patients who might otherwise have limited access options, and a dedicated on-call nurse provides around-the-clock coverage.

Why Referral to Academic Centers Carries Retention Risk

A recurring theme across the panel was the strategic cost of referring patients out for step-up dosing. Boccia drew a direct comparison to early venetoclax adoption, when concerns about tumor lysis syndrome led many community practices to send patients to academic centers for management—a hesitancy that has since largely disappeared as comfort with the agent grew. He argued bispecifics are on a similar trajectory and that practices delaying adoption risk losing patients permanently rather than temporarily.

Return rates after academic referral are "very variable depending on the relationship," Boccia noted, adding that many community oncologists trained at the same academic centers they might refer to, and already carry the clinical background needed to manage these therapies themselves.

Meeting patients where they are is essential for independent practices. Ajayi noted that Highlands Oncology serves a 50-mile radius across its 4 clinics. The nearest major academic alternative requires a 2.5-hour commute, which made establishing an in-house bispecific program crucial to ensuring regional patients could receive advanced care without facing significant travel burdens.

Scaling Safely and Managing Toxicity

Pre-survey results from the roundtable's participants confirmed the national picture: practice models ranged from fully inpatient step-up to fully outpatient, with many sites operating on a case-by-case basis depending on the patient and the drug. Volume varied from fewer than 5 patients per week to more than 50. The core panelists represent distinct points on this curve: while KU manages roughly 30 hematologic patients weekly across its network, independent community practices like Highlands Oncology and Boccia’s local clinic operate at a highly targeted scale, averaging 2 to 3 patients per week.

This practice heterogeneity is underscored by an active clinical debate regarding adverse event mitigation. "I will die on this hill," Mahmoudjafari stated, emphasizing KU’s strict institutional stance against routine prophylactic tocilizumab. Conversely, Boccia noted that his practice routinely utilizes prophylactic tocilizumab for myeloma patients to mitigate cytokine release syndrome.

Ultimately, the panelists agreed that this operational variety is not a flaw but a feature. The right model depends heavily on patient acuity, the specific drug, staffing constraints, and a system's immediate ability to rescue a patient if severe toxicity develops. Mahmoudjafari noted that survey responses taken even a year earlier would likely have looked markedly different, underscoring how quickly practice norms are changing as the field matures and clinical comfort grows.