New Cancer Drugs Test the Limits of Care Delivery

Across many disease settings in oncology, treatment choices now hinge on patient preferences, toxicity, and logistics as much as on results. Infusion chair time, inpatient bed capacity, staff certification, and referral pathways repeatedly surface as limiting factors on newer therapies. Especially within oncology, which now has more effective drugs than many practices can comfortably deliver, the recurring questions are less about whether these agents work and more about how to choose among them, manage their toxicities, and get them to all patients.

At the August 20 Institute for Value-Based Medicine^® evening, “Pioneering the Next Era of Oncology Care,” held in New York, New York, throughout 4 discussions that covered breast cancer, multiple myeloma (MM), leukemia and lymphoma, and genitourinary (GU) cancers, clinicians weighed new antibody-drug conjugates (ADCs), bispecific antibodies, chimeric antigen receptor (CAR) T-cell therapies, and radioligands. The umbrella theme across all 4 panels: Bring together academic centers, community practices, and payers to build collaborative models to fit novel treatments.

How Breast Oncologists Are Choosing Among New ADCs

The opening session, moderated by Maryam Lustberg, MD, MPH, director of the Center for Breast Cancer at Smilow Cancer Hospital and Yale Cancer Center, and chief of breast medical oncology at Yale, focused on the gray zones created by a crowded pipeline. Lustberg was joined by Nicole Casasanta, MD, instructor of medicine (medical oncology and hematology) at Smilow Cancer Hospital and Yale Cancer Center, and Pedram Razavi, MD, PhD, MPH, breast medical oncologist at Memorial Sloan Kettering Cancer Center (MSK).

In metastatic triple-negative breast cancer, which makes up 10% to 15% of breast cancers but carries the worst prognosis,¹ two ADCs now have first-line indications: sacituzumab govitecan² and datopotamab deruxtecan (Dato-DXd).³ Casasanta said she leans toward Dato-DXd for patients who relapse within 6 months of curative-intent therapy, citing higher response rates. Razavi said he favors Dato-DXd when debulking is needed, but is strict about prophylactic eye drops and mouthwash to prevent ocular toxicity and grade 3 stomatitis. Lustberg noted that sacituzumab govitecan holds a National Comprehensive Cancer Network category 1 recommendation.

In early HER2-positive disease, the panel discussed trastuzumab deruxtecan (T-DXd) approvals based on the DESTINY-Breast11 trial (NCT05113251) in the neoadjuvant setting⁴ and the DESTINY-Breast05 trial (NCT04622319) in high-risk patients with residual disease.⁵ Razavi said the neoadjuvant regimen improved pathologic complete response with fewer hematologic adverse events, whereas the 14-cycle adjuvant course carried more interstitial lung disease, including 2 deaths. Casasanta said she follows trial eligibility rather than the broader label, noting that a taxane plus dual HER2 blockade yields complete response rates of 40% to 60%.

In first-line metastatic disease, Casasanta noted that the DESTINY-Breast09 (NCT04784715), PATINA (NCT02947685), and HER2CLIMB-05 (NCT05132582) trials were not compared head-to-head and that continuous T-DXd is a heavier burden than maintenance strategies. Razavi described HERizon-Breast (NCT07459673), an MSK trial using circulating tumor DNA, as a potential indicator of when to escalate or stop treatment with curative intent.^6,7 For hormone receptor–positive disease, he highlighted the VIKTORIA-1 trial (NCT05501886), in which the pan-PI3K/mTOR inhibitor gedatolisib extended progression-free survival (PFS).

Why Myeloma Experts Still Favor CAR T First

Moderated by Suzanne Lentzsch, MD, PhD, director of the multiple myeloma and amyloidosis program at Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, the MM panel began with a discussion on care delivery. Lentzsch highlighted the newly approved on-body device for isatuximab⁸ and how it cuts reactions from approximately 25% with intravenous dosing to 1.5%.⁹ Mateo Mejia Saldarriaga, MD, hematologist/oncologist at Weill Cornell Medicine and NewYork-Presbyterian, said freeing nurse time and long first-dose slots could ease chair-time constraints in busy infusion centers.

However, most of the panel was concentrated on sequencing in early relapse. Rajshekhar Chakraborty, MD, assistant professor of medicine in the Division of Hematology/Oncology at Columbia, said the MajesTEC-3 trial (NCT05083169) of teclistamab plus daratumumab produced a 3-year PFS rate of close to 83%, and he would choose that regimen over CAR T-cell therapy for daratumumab-naive patients. Adriana Rossi, MD, assistant professor of medicine (hematology and medical oncology) and director of CART and the stem cell transplant clinical service at the Center of Excellence for Multiple Myeloma at Mount Sinai, argued that eligible patients should first receive CAR T-cell therapy because prolonged exposure to bispecific B-cell maturation antigen may blunt later CAR T-cell response. She added that only about 10% of eligible patients nationally ever receive CAR T-cell therapy. Mejia Saldarriaga and Natalia Neparidze, MD, associate professor of internal medicine (hematology) and research leader of the myeloma program (hematology) at Yale School of Medicine, agreed that disease tempo, caregiver support, and patient preference often decide the question.

On safety, Rossi said better bridging therapy and starting steroids when the absolute lymphocyte count exceeds 3000 have reduced delayed neurotoxicity. The panelists described primary intravenous immunoglobulin (IVIG) as essential with bispecifics. Chakraborty said Columbia has had no infection-related deaths since adopting routine IVIG, whereas Neparidze said Yale has begun giving CAR T-cell therapy on an outpatient basis to a highly selected group. The panelists agreed that newly approved iberdomide¹⁰ should mainly be utilized in a bridging or later-line setting.

What Keeps Bispecifics and CAR T Out of Community Practice

The leukemia and lymphoma panel shifted to access. Moderator Oscar B. Lahoud, MD, chief medical officer at NYU Langone Hospital–Brooklyn, was joined by Prioty Islam, MD, MSc, clinical director of the leukemia service at MSK, and Douglas Gladstone, MD, chief of hematologic malignancies at Northwell Health Cancer Institute. Gladstone said bispecifics are poised to rewrite lymphoma care, but community practices are facing economic hurdles, including uneven reimbursement across formulations and staff certification requirements. Lahoud added that step-up dosing requires proximity to a hospital that can manage cytokine release syndrome and that inpatient doses are folded into the hospital’s diagnosis-related group payment, leaving little incentive to absorb these admissions. He proposed academic hubs handling outpatient step-up dosing and then returning patients to community oncologists for maintenance. Islam compared the current unease to the early years of monoclonal antibodies.

Access to CAR T-cell therapy drew sharp criticism. Lahoud noted that most eligible patients never receive it and that Manhattan has few centers that offer this therapy, whereas Brooklyn, Staten Island, and Queens have none. Underinsured patients and those with government coverage face particular travel burdens, and Islam said MSK’s regional sites remain under-resourced for patients needing inpatient monitoring. Gladstone said Northwell aims to return patients to their local oncologists by day 60, although some practices hesitate to take them back.

These panelists favored collaboration over consolidation, and Islam called for medical records that move freely across health systems. On insurance, Lahoud said some payers still mandate inpatient step-up dosing because of label language, which he described as a misuse of scarce beds, while Gladstone described regular denials despite peer-to-peer review.

How Biomarkers Are Reshaping GU Cancer Care

The closing GU session, moderated by Daniel P. Petrylak, MD, of the Yale School of Medicine, focused on testing. He was joined by panelists David H. Aggen, MD, PhD, of MSK; Scott T. Tagawa, MD, MS, FACP, FASCO, of Weill Cornell Medicine; and Raymond DeMatteo, PharmD, BCOP, of MSK.

Prostate cancer now has 3 clinically actionable biomarkers: prostate-specific membrane antigen PET, DNA damage repair alterations such as BRCA2, and PTEN loss by immunohistochemistry. Tagawa noted that nearly all lung cancers undergo molecular testing, whereas many prostate cancers still do not, and Petrylak urged germline and somatic testing for every patient with metastatic hormone-sensitive disease. Radioligand therapy remains harder to access outside large centers due to PET availability and nuclear medicine logistics.

In bladder cancer, the panel discussed adding durvalumab to BCG for non–muscle-invasive disease based on the data from the POTOMAC trial (NCT03528694). Aggen called it reasonable for patients determined to avoid cystectomy, framing value partly as bladder preservation, while Petrylak noted that a cystectomy costs roughly $50,000 before postoperative care.¹¹ Perioperative enfortumab vedotin plus pembrolizumab has produced pathologic complete response rates near 60%, which Aggen said raised hard questions about who still needs their bladder removed. DeMatteo said finite perioperative courses may prove cost-effective.

For kidney cancer, the panel reviewed adjuvant belzutifan plus pembrolizumab for high-risk clear cell renal cell carcinoma after nephrectomy, which improved disease-free survival in the LITESPARK-022 trial (NCT05239728). Aggen noted the lack of biomarkers to identify who needs escalation, and DeMatteo said anemia is manageable with dose holds and erythropoietin. Asked about the long-term risks as PARP inhibitors and radioligands are used earlier, the panelists pointed to adaptive dosing, baseline screening for clonal hematopoiesis to assess myelodysplastic syndrome risk, kidney monitoring, and close follow-up.

References

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8. Caffrey M. FDA approves isatuximab on-body injector, raising anti-CD38 competition in myeloma. AJMC. Updated July 11, 2026. Accessed October 18, 2026. https://www.ajmc.com/view/on-body-injector-for-sanofi-s-isatuximab-approved-by-fda-upping-anti-cd38-competition-in-myeloma
9. McCormick B, Leleu X. Isatuximab OBI cuts infusion reactions: Xavier Leleu, MD, PhD. AJMC. July 28, 2026. Accessed October 18, 2026. https://www.ajmc.com/view/isatuximab-obi-cuts-infusion-reactions-xavier-leleu-md-phd
10. Shaw ML. FDA approves novel iberdomide regimen in RRMM. AJMC. August 13, 2026. Accessed October 18, 2026. https://www.ajmc.com/view/fda-approves-novel-iberdomide-regimen-in-rrmm
11. Bladder removal cystectomy. MD Save. Accessed October 18, 2026. https://www.mdsave.com/procedures/bladder-removal-cystectomy/d78afccb