Panel Confronts the Practical Barriers to Bringing Bispecifics Into Community Myeloma Care

Multiple myeloma specialists have spent the past several years absorbing a wave of new T-cell–engaging bispecific antibodies, and the conversation has now shifted from whether these agents work to how community practices without academic infrastructure can safely deliver them. That shift was the focus of a Stakeholder Interchange convened by The American Journal of Managed Care® (AJMC®) on July 28, 2026, in Houston, Texas, part of this year’s series examining bispecific antibody adoption in early relapse relapsed/refractory multiple myeloma (RRMM).

The discussion, moderated by Robert Z. Orlowski, MD, PhD, chairman ad interim and director of myeloma at The University of Texas MD Anderson Cancer Center, brought together 9 faculty members spanning academic medical centers and community oncology practices across the Houston metropolitan area. Four participants were from UTHealth Houston and Memorial Hermann Cancer Center–Texas Medical Center: Adan Rios, MD; Sara Taveras Alam, MD; Natalie Rafaeli, MD; and Frances Cervoni-Curet, MD. They were joined by Sarvari Yellapragada, MD, of MD Anderson; Branden Hsu, MD, of Texas Oncology–Houston Memorial City; and Rammurti “Ram” Kamble, MD, of Texas Oncology–Deke Slayton Cancer Center in Webster. Rounding out the group were pharmacists Thomas Pessia, PharmD, of Texas Oncology in The Woodlands, and Christina Rivera, PharmD, of Houston Methodist.

Orlowski framed the discussion around a rapidly evolving treatment landscape: teclistamab (Tecvayli; Johnson & Johnson) plus daratumumab (Darzalex; Johnson & Johnson) is now a category 1 recommendation per National Comprehensive Cancer Network (NCCN) guidelines after just 1 prior line of therapy,¹ based on the MajesTEC-3 regimen,² provided patients have already received lenalidomide and a proteasome inhibitor, while chimeric antigen receptor (CAR) T-cell therapy has also moved earlier, with ciltacabtagene autoleucel, or cilta-cel (Carvykti; Legend/Johnson & Johnson) available as early as second line and idecabtagene vicleucel, or ide-cel (Abecma; Bristol Myers Squibb) as early as third line. With no formal sequencing guidance from NCCN, panelists spent much of the evening working through how they are choosing between these options in practice—and what needs to change operationally to deliver bispecifics safely outside the hospital.

Bispecifics vs CAR T: An Evolving Decision Process

The panel’s opening exchange centered on where teclistamab- or talquetamab-based regimens fit relative to CAR T-cell therapy, now that both are approved in earlier relapse. For Rios, the appeal of bispecific antibodies is fundamentally about access. “These antibodies have more degree of affinity for their target. They are more effective in triggering the T-cell responses,” Rios said, adding that “the availability off the shelf is going to be a great advantage in overcoming the barriers of the CAR T.”

Kamble described the second-line decision as genuinely unsettled. “Second line is a huge problem,” he said. “You want to give CAR-T, but you can’t give it to everybody—very select patients. If you can get CAR-T, then it makes sense” to pursue it before defaulting to a bispecific-based regimen.

Yellapragada agreed that dosing schedules are narrowing whatever edge that CAR T-cell therapy retains, particularly as maintenance intervals on bispecifics stretch from weekly to monthly. “I think as we move towards time-limited therapy, both the risk of infections as well as the pressure on the [myeloma] cell to mutate as you keep on exposing it to BCMA therapy, both those risks—theoretical risks—will reduce,” she said. For patients with aggressive disease, “we don’t often have that luxury of time to get to CAR right away.” This makes use of bispecific antibodies a more practical bridge.

“It’s crazy how quickly it’s evolving,” Rafaeli said, summing up the pace of change. “It’s really difficult to keep up, to be honest.” For patients who are candidates for both types of treatment, sequencing questions remain.

Pessia described how such a case is unfolding in his practice. “We’re actually trying to get a talquetamab regimen right now for one of our patients over teclistamab,” he said. Unlike teclistamab, which targets B-cell maturation antigen (BCMA) on myeloma cells and CD3 on T cells,³ talquetamab (Talvey; Johnson & Johnson) targets GPRC5D on myeloma cancer cells and CD3 on healthy T cells.⁴ The physician treating the patient is concerned that giving a BCMA-directed bispecific would “basically ruin” the chances of CAR T-cell therapy working later on, should the patient relapse. Evidence presented last year at the American Society of Hematology supports this concern.⁵

“So, he’s kind of holding that CAR-T in his back pocket for that reason,” Pessia said.

Building Outpatient Capacity Looks Different Across Houston

Asked about their experience initiating step-up dosing, panelists described a patchwork of approaches shaped as much by geography and hospital partnerships as by clinical judgment. Hsu, practicing on Houston’s west side, said his group has not yet been able to bring step-up dosing in-house. “For a community, I’ve just been referring everybody to the medical center. We just don’t have the capability at our local hospitals for step-up dosing, and I don’t think there are any plans on the west side of Houston to have any hospitals certified,” he said, referring to meeting requirements of a Risk Evaluation and Mitigation Strategy (REMS).⁶

Kamble described a more advanced model at Texas Oncology’s Deke Slayton Cancer Center, where step-up dosing now happens largely without full hospital admission. “We do that step-up dosing for the majority of Texas Oncology...we are hospitalizing only for 23-hour observation, and not seeing much problem with this,” he said, comparing the current anxiety around bispecifics to how oncologists once treated tumor lysis syndrome as a major event. “That’s where we will be in a few years’ time with these things.”

Pessia’s Woodlands practice relies on proximity to a partner hospital. “We’re lucky because Memorial Hermann is literally right across the parking lot, so we can transfer the patient over there fairly quickly and easily,” he said of managing cytokine release syndrome (CRS) events during step-up.

At Houston Methodist, Rivera described a hybrid approach designed to shorten inpatient time without sacrificing safety. “We do a hybrid. The patients go inpatient, and then before we even start inpatient step-up dosing, we’ve already obtained the outpatient insurance approval...they start inpatient and they go outpatient quite quickly,” she said.

Memorial Hermann–Texas Medical Center, where Rios, Taveras Alam, Rafaeli, and Cervoni-Curet practice, has moved more cautiously. “We started fairly early with the bispecifics, so we were educated by the pharmaceutical industry, and at the time the intent was really to do inpatient,” Rios said. “We have continued that practice, and we’re now moving slowly to more outpatient.”

Rafaeli said disease burden and socioeconomic factors, more than institutional protocol, drive that decision on a case-by-case basis. “The burden of disease and kind of the socioeconomic situation, health literacy factors into our decision, whether to start inpatient or outpatient.”

Taveras Alam said her team is following the same trajectory, citing caregiver support and disease burden as the operative variables.

Patient Selection Comes Down to Caregivers, Disease Burden—and a Hard Question About Who Gets Left Out

When Orlowski turned the discussion to eligibility criteria for outpatient administration, Rafaeli offered what she framed as her group’s consensus hierarchy. “I think our group will probably agree that disease burden is number one in terms of the decision for outpatient...insurance status does play a very big role,” she said, ranking a combination of patient health literacy and caregiver access as a close third, “because if the patient doesn’t understand what they’re submitting themselves to, what those side effects are going to be, the risk of infections, which we know are very high.”

Hsu tied eligibility directly to hospital readiness. “If you don’t have the hospital support for any problems and we have to send the patient to the [emergency department], it’s going to be a waste of the patient’s effort.” He and Rios both argued that reimbursement for prophylactic tocilizumab, if secured, would make outpatient administration close to routine. “I think that’s the direction, right? I think that’s what everybody’s doing in the next couple years,” Hsu said.

Pessia challenged that consensus, citing the cost of prophylactic tocilizumab. “Why are we doing studies on prophylactic [tocilizumab] and not prophylactic [dexamethasone]? Dex is...a whole lot cheaper than toci,” he said, although he agreed that patient selection is the most important factor. “I don’t think that every patient is good for a bispecific.”

The panel’s most pointed exchange concerned patients who lack reliable caregiver support. Kamble described a screening approach he uses in the first minutes of every new bispecific consultation. “The 2 questions I ask within 5 minutes: Did you walk from the parking lot? And who do you live with? That helps me so much to put my energy into perspective rather than just wasting it.”

Rios pushed back on the implication that solitary patients should be excluded, describing the dilemma as a genuine ethical burden. “It’s a huge barrier, andIt creates an enormous angst in the physician, because the decision—should I treat, should I not treat? If I treat, what is my responsibility if things don’t go well?” he said, noting that patients can end a physician relationship far more easily than a physician can decline to continue one. Yellapragada offered a counterpoint, describing a wheelchair-bound patient in his 40s whose wife—his only caregiver—was unavailable for much of the year; after several visits to build the patient’s own understanding of warning signs, she proceeded with treatment. “I don’t think it’s so much just ambulatory or not ambulatory. I don’t think it’s that simple, at least for me,” she said.

Training, Hospital Partnerships, and an Emergency Department That “Can’t Keep Track”

Extending bispecific access beyond flagship centers, panelists agreed, depends less on the expertise of the physician administering the treatment than on training everyone else interacting with the patient. The biggest wild cards involve emergency departments (EDs) that may see a bispecific-treated patient rarely. Cervoni-Curet, whose husband is an emergency medicine physician, said the specialty’s breadth works against disease-specific education efforts. “Every time I talk to the department, they say, “We can’t keep track. Can you just tell us which drugs in oncology we need to know?’ They’re not just dealing with oncology; they’re dealing with cardiothoracic surgery,” and everything else that walks through the door, she said.

Kamble, who has worked to train ancillary staff at his own institution, agreed this the hardest audience to reach: “The ED staff is the hardest people to train,” he said, describing his own approach as starting with support staff and building up: “My teaching starts from the housekeeper. I go bottom up.”

Pessia described a successful hospital partnership built at the physician level. “Dr [Andrew] Jackson really set up our rapport with Memorial Hermann in the Woodlands directly, and got with the head of the whole hospital...we set up training for our staff and then sent the training over to the hospital setting so that they would also get staffed and trained as well.”

But Rivera and Rafaeli both noted tocilizumab availability still varies by hospital campus within the same system, and Rivera described a case in which tocilizumab shipped between 2 Memorial Hermann facilities missed a patient who was simultaneously being transferred the opposite direction. “We acknowledge that this is a problem in the system,” Taveras Alam said, noting her institution now emphasizes directing patients to a specific facility even in an emergency. Rafaeli placed the challenge in a broader context of staffing turnover. “It comes down to the training of the ancillary staff more so than the availability of us as clinicians and pharmacists...how many of these nurses want to pursue oncology training?”

Prophylaxis, Infection Risk, and the Economics of Keeping Patients Out of the Hospital

Infection prevention drew sustained attention, with Yellapragada describing her institution’s standard prophylaxis for patients on daratumumab-based regimens. “We’re giving PJP [Pneumocystis jirovecii pneumonia] prophylaxis in addition to just monthly IVIG [intravenous immunoglobulin], regardless of the IgG level,” she said. “If you have the [hepatitis B] core antibody positive, regardless of the surface antibody, we are covering” with an antiviral.

Orlowski endorsed starting IVIG early rather than waiting for hypogammaglobulinemia to develop, since most circulating immunoglobulin in patients with IgG myeloma is nonfunctional even when total levels appear normal.

Data presented during the session reinforced the economic case: an analysis of health care resource use found total per-patient costs during step-up dosing were lower with an outpatient, prophylactic-tocilizumab approach than with inpatient management reserved for reactive CRS treatment—differences ranging from roughly $8500 to more than $12,000 per patient, driven mainly by reduced inpatient days.⁷ Still, Pessia relayed a case in which an insurer denied tocilizumab outright, instead requiring use of biosimilar alternatives that are unavailable through the practice’s distributor.

“Even if we could give this, we can’t, because we don’t have the right toci,” he said, “because the insurance company’s not going to pay for it.”

Payer Access: Prior Authorizations, Denials, and an Ally in AI

The session’s second case study involved a 50-year-old patient whose disease relapsed disease after quadruplet therapy and transplant; she was employed full time and caring for her own parents. For this reason, she declined CAR T-cell therapy, but she worried about the cost of teclistamab plus daratumumab.^2,8 This case prompted the most direct conversation about payer strategy. Rivera’s suggestion drew immediate interest from colleagues: “Utilizing AI to write your prior authorization letters,” she said, describing how her institution’s clinical pharmacists have begun incorporating the technology into appeals.

Taveras Alam said the more durable strategy is documentation discipline rather than any particular tool. “The key is using whatever the FDA approval is for the combination in your progress note. You have to make it very clear what you’re doing and why you’re doing it,” she said, recalling a denial that resulted when an outdated note was submitted with a resubmission. Ironically, this resulted in the patient taking a more expensive regimen.

“I have a patient who had been on [daratumumab] maintenance for myeloma, and the insurance required like a resubmission of authorization,” Taveras Alam said. “They denied the continuation of dara, so she was off dara for several months, relapsed, and now I have her on dara-teclistamab, which they approved with no problem.

Orlowski asked if the physicians at Memorial Hermann Cancer Center–TMC knew whether this patient ended up absorbing the cost of the new regimen with teclistamab. “No idea,” Rafaeli replied.

And Orlowski acknowledged that if the same happened at his institution, he wouldn’t know, either.

Cervoni-Curet pointed to a more preventive approach: understanding each payer’s specific coverage policies before submission, rather than relying solely on FDA labeling language, which does not always align with an individual plan’s criteria. Rafaeli said this is where specialized pharmacy staff prove indispensable: “The pharmacist knows which insurances, by patient volume...they get very familiar with which policies apply to what,” including what documentation a specific payer wants beyond the FDA or NCCN citation alone.

Hsu offered a sobering anecdote during the AI discussion: A family member who processes chemotherapy authorizations for a major benefit management company told him that payers are now using AI to analyze practices’ own appeal letters, allowing them to refine their denial responses. Several panelists agreed that even routine claims, such as IVIG, can generate more friction than the bispecific regimens themselves. Rafaeli said she has had more coverage difficulty with IVIG than with the bispecific antibodies. On documentation strategy, Pessia and Orlowski agreed that pairing an immunodeficiency diagnosis code with a hypogammaglobulinemia code substantially improves the odds of approval.

The REMS certification process, by contrast, drew relatively little frustration. “This is the easiest REMS to do,” Taveras Alam said, though Pessia noted the 4 separate manufacturer programs differ in their reauthorization requirements and suggested standardizing them would ease the burden as more clinics take on bispecific administration.

Orlowski closed by returning to the volume challenge underlying the discussion: with bispecific antibodies now recommended after a single prior line of therapy, and CD38-targeted agents increasingly used in the frontline setting, the pool of eligible relapsed patients is only going to grow.

“It used to be a decade between new myeloma therapies,” he said. “Now if a month goes by without a New England Journal phase 3 paper, it’s been a bad month for the myeloma group.”

References

1. Kumar SK, Callander NS, Adekola K, et al. Multiple Myeloma, Version 5.2026, NCCN Clinical Practice Guidelines In Oncology. J Natl Compr Canc Netw. 2026;24(1):e260001. doi: 10.6004/jnccn.2026.0001
2. Costa LJ, Bahlis NJ, Perrot A, et al, for the MajesTEC-3 Trial Investigators. Teclistamab plus daratumumab in relapsed or refractory multiple myeloma. N Engl J Med. 2026;394(8):739-752. doi: 10.1056/NEJMoa2514663
3. Moreau P, Garfall AL, van de Donk NWCJ, et al. Teclistamab in relapsed or refractory multiple myeloma. N Engl J Med. 2022;387(6):495-505. doi:10.1056/NEJMoa2203478
4. Rasche L, Schinke C, Touzeau C, et al. Talquetamab in patients with relapsed/refractory multiple myeloma: 3-year follow-up of the phase 1/2 MonumenTAL-1 study. Blood. Published August 6, 2026. doi:0.1182/blood.2025031994
5. Reyes K, Lipof J, Kwek S, et al. Impact of prior BCMA-targeted therapy on CAR-T expansion and host T-cell phenotypes in patients with relapsed/refractory multiple myeloma receiving BCMA CAR-T therapy. Blood 2025; 146(Suppl 1): 3916. doi: https://doi.org/10.1182/blood-2025-3916
6. Risk Evaluation and Mitigation Strategies. FDA website. May 20, 2025. Accessed September 19, 2026. https://www.fda.gov/drugs/drug-safety-and-availability/risk-evaluation-and-mitigation-strategies-rems
7. Ali A, Kaur A, Yang F, et al. Economic value of tocilizumab prophylaxis to prevent cytokine release syndrome (CRS) during outpatient teclistamab (Tec) or talquetamab (Tal) initiation for relapsed/refractory multiple myeloma (RRMM). Presented at: International Myeloma Society Annual Meeting, September 17, 2025; Toronto CA. PA-008.
8. Irfan S, Jamil MA, Abid MB. Cost-effective analysis of teclistamab and daratumumab versus ciltacabtagene autoleucel in relapsed multiple myeloma. Br J Haematol. 2026;209(2):778-781. doi: 10.1111/bjh.70607