Multiple Myeloma Care Now Hinges on Delivery, Not Efficacy: Hans Lee, MD

Response rates in multiple myeloma have moved from roughly 30% with monoclonal antibodies and oral therapies to more than 60% with T-cell redirecting therapies and above 90% with chimeric antigen receptor (CAR) T-cell therapy. Yet, most eligible patients still cannot access these treatments where they live, Hans Lee, MD, director of myeloma research at Sarah Cannon Research Institute, said in an interview with The American Journal of Managed Care^® at a recent Institute for Value-Based Medicine® event in Nashville, Tennessee.

What Changed in the Past 3 to 5 Years

CAR T-cell therapies and bispecific T-cell antibodies ushered in a new era after 2 decades of steadier progress, Lee said. He credited a convergence of stakeholders, spanning researchers, academic and community centers, the FDA, patient advocacy, and industry, united around therapies that work better and improve quality of life.

The shift reset expectations. Where progression previously came at 3 to 4 months, durability now runs at least a year and sometimes 2 or 3. The next stage is execution, as patients should receive these therapies wherever they live, not only at large centers, Lee said.

Framing the Second-Line Choice

With both bispecifics and CAR T-cell therapies approved in the second line, Lee said he walks patients through both in detail, noting one size may not fit all.

CAR T is a single infusion with no therapy afterward in its current iteration. That time off therapy and durability of response are attractive, particularly to younger patients with active lifestyles. The tradeoff is a more involved front end, as treatment requires an equipped center, possible travel, and a stay there that not all patients can manage.

Bispecifics are available to nearly anyone, including elderly and frail patients, with high response rates and infection risks that prophylaxis can mitigate. Although they are a continuous therapy, patients develop deep responses rapidly, and Lee noted he expects more fixed-duration approaches of 1 to 2 years followed by time off therapy.

Why CRS Preparedness Determines Local Delivery

Cytokine release syndrome (CRS) applies to both classes early in administration and has been a barrier for many centers, since delivery requires mobilizing stakeholders and educating patients and families. Prophylactic tocilizumab has cut CRS incidence from 60% to 70% down to under 10% to 15%, Lee said. The most common CRS is grade 1, a fever, which he noted is fairly manageable.

Lee emphasized the importance of gathering stakeholders and building a plan. He said he expects more sites activated for local step-up dosing, with CAR T following. Vast swaths of the country still lack access, however, and Lee argued the field is not solving the problem if it is solved only for a few.