Patient, Disease Factors Shape Multiple Myeloma Treatment Decisions

The choice of therapy at first relapse in multiple myeloma has grown considerably more complex as chimeric antigen receptor (CAR) T-cell therapy, bispecific antibody combinations, and, more recently, an FDA-approved cereblon E3 ligase modulator agent have all become viable options, Amandeep Godara, MBBS, explained in an interview at a recent Institute for Value-Based Medicine® event in Salt Lake City, Utah.

Godara, moderator of the “Scaling Innovation: Delivering Targeted Therapies, CAR-T and Bispecifics in Multiple Myeloma” panel, noted that the discussion with patients has become far more nuanced than it was even a few years ago. Available data suggest CAR T-cell therapy and bispecific antibody combinations remain the most effective options when both are accessible, he highlighted, but deciding between them and against other emerging therapies now requires weighing a wider set of patient and disease variables than before.

For treatment decisions, Godara said he considers patient age, comorbidities, and distance from the treatment center; distance affects the feasibility of setting up either immunotherapy. He emphasized that patients should be fully informed not only about how effective these therapies are against multiple myeloma but also about the logistical demands each one carries.

Regarding disease, the aggressiveness of the relapse and the extent of disease burden are central considerations during treatment selection, Godara said. Because CAR T-cell therapy requires time for T-cell collection and several weeks of manufacturing, patients with substantial disease burden need an effective bridging strategy in place before starting. He noted that as the treatment landscape has expanded, nearly all his patients now have some viable bridging option available if CAR T-cell therapy is the chosen path.

By contrast, Godara said bispecific antibodies require no bridging therapy and can begin as soon as a patient is consented and insurance authorization is secured, making them more readily available in the clinic. CAR T-cell therapy also demands a longer commitment at the treatment center, whereas bispecific initiation typically requires only 6 to 7 days before patients can transfer back to their local oncologist.

Although no head-to-head trial exists, Godara pointed to cross-trial data suggesting that CAR T-cell therapy and bispecific combinations show similar long-term efficacy despite being mechanistically distinct, with different toxicity profiles and different demands on patients and care teams.

"It's a more nuanced discussion that's becoming of late in our clinics," Godara said.