What Comes Next: Taking on Unanswered Questions in Multiple Myeloma

Advances in the care of patients with multiple myeloma have been extraordinary: Treatment advances over the past 15 years mean that patients who once had a life expectancy of 3 years can now expect to live 10 years or more.¹

But access to these new drugs and regimens is not the same for everyone. Whether it’s anti-CD38–based quadruplets for newly diagnosed disease, bispecific antibodies and chimeric antigen receptor (CAR) T-cell therapy in earlier lines of care, or the forthcoming cereblon E3 ligase modulators (CELMoDs) for those who relapse,² the treatments that patients with myeloma receive are greatly affected by their socioeconomic background, where they live, and especially by who pays—with insurers and out-of-pocket costs playing outsized roles in decisions.

With this in mind, on May 2, 2026, The American Journal of Managed Care® hosted “Bridging the Gaps in Health Equity & Access in Multiple Myeloma.” The daylong meeting in Tampa, Florida, brought together an extraordinary group of leaders in multiple myeloma treatment and research, from those on the front lines of drug development to those who have pushed the boundaries of outpatient administration. Leading the sessions were Peter Voorhees, MD, a member of the Hematology Department at Atrium Health Levine Cancer Institute and a professor of Cancer Medicine at the Wake Forest University School of Medicine in Charlotte, North Carolina; and Doris Hansen, MD, a professor and specialist in blood and marrow transplant and cellular immunotherapy at Moffitt Cancer Center in Tampa.

In both the morning session, which focused on patients with newly diagnosed disease, and the afternoon session, which addressed relapsed and refractory myeloma, faculty took part in consensus discussions that will be presented in a forthcoming peer-reviewed supplement. Both sessions concluded with a “nonconsensus discussion” in a roundtable format, which addressed unsettled emerging topics. Those discussions are summarized here.

Participating faculty were:

• Salman Fazal, MD, hematologist and transplant physician, hematology lead at UPMC Hillman Cancer Center, Harrisburg, Pennsylvania;
• Gustavo Fonseca, MD, FACP, hematologist/oncologist and director, Research & Clinical Trials, Florida Cancer Specialists & Research Institute;
• Alfred Garfall, MD, MS, associate professor of medicine, University of Pennsylvania and director, Autologous Hematopoietic Stem Cell Transplantation, Cell Therapy and Transplant Program at the Hospital of the University of Pennsylvania;
• Gurbakhash Kaur, MD, oncologist/hematologist and assistant professor of medicine at Tisch Cancer Institute, Icahn School of Medicine at Mt Sinai;
• Harsh Parmar, MD, assistant professor of medicine, John Theurer Cancer Center, Hackensack Medical Center in New Jersey;
• Tyler Sandahl, PharmD, clinical pharmacist, Mayo Clinic, Rochester, Minnesota;
• Douglas Sborov, MD, MS, associate professor at University of Utah/Huntsman Cancer Institute and director, HCI Hematology Disease Center and Plasma Cell Dyscrasias (PCD) Program;
• Mansi Shah, MD, associate professor of medicine, Division of Blood Disorders, Rutgers Cancer Institute/RWJ Barnabas Health in New Jersey;
• Cindy Varga, MD, associate professor, Atrium Health Levine Cancer Institute; and
• Andrew Yee, MD, clinical director, Center for Multiple Myeloma at Mass General Brigham Cancer Institute.

Newly Diagnosed Multiple Myeloma: Maintaining Equity as Costly Therapies Shift to Earlier Lines

Voorhees opened the session by focusing on 3 key challenges: how bispecific antibodies entering the front line may widen or narrow health equity gaps, how institutions can account for the financial toxicity of prolonged multidrug regimens, and what metrics should guide equitable delivery of novel therapies across demographic groups.

He guided a discussion that has been burning for more than a year, since the first data from MajesTEC-5 (NCT05695508) were unveiled in December 2024 (and updated in June 2026).³ As studies of combinations involving teclistamab (Tecvayli; Johnson & Johnson) signal that bispecific antibodies may soon become components of front-line myeloma therapy,⁴ will this shift equalize or deepen disparities between academic centers and community practices?

Community Practices in Control. Sborov argued that the answer depends almost entirely on whether community oncologists act now. “You have to learn how to give these drugs because they're coming to the front line," he said, warning that patients treated by practitioners unwilling to adopt bispecifics could receive suboptimal care. Garfall offered a broader frame: Bispecifics are not niche myeloma agents. They are already reshaping treatment in diffuse large B-cell lymphoma, and approvals in solid tumors—including small cell lung cancer (SCLC) and prostate cancer—mean that community oncologists across disease types are already building familiarity with the drug class.

Sandahl, who has guided Mayo Clinic’s efforts in outpatient administration of myeloma bispecifics, agreed, noting that the approval of agents such as tarlatamab (Imdelltra; Amgen) for SCLC is pushing community practices to develop bispecific infrastructure that may then transfer to myeloma. “We’re seeing a lot more expansion because community providers are seeing way more lung cancers than myeloma patients,” she said.

Educating the Ecosystem. The challenge is beyond training community oncologists, Varga said, but involves the entire ecosystem of care. Emergency department physicians, hospitalists, and nocturnists who manage complications such as cytokine release syndrome (CRS) need education as well. Garfall pushed back on the CRS framing, suggesting the term itself creates unnecessary alarm. “We should just call it fever,” he said, arguing that the severity profile of bispecific-related CRS is substantially less complex than what is seen with CAR T-cell therapy, and that community oncologists routinely manage drugs of comparable or greater complexity.

Fazal noted that scheduling constraints compound the issue: Step-up dosing regimens may require patients to present on weekends, which some community practices restructure into weekly schedules to preserve operational feasibility, potentially deviating from the label. Neurological adverse events—even when unrelated to the bispecific—also create disproportionate hesitancy in community settings where attribution is uncertain.

Different Takes on Uptake. Shah offered a counterintuitive perspective: Moving bispecifics into earlier lines may actually accelerate community uptake rather than slow it. Historically, community oncologists have deferred difficult fifth-line decisions to academic centers. But as these agents become standard in second or third lines, the decision-making calculus shifts. She predicted a corresponding decline in CAR T referrals as community practitioners become more empowered to make the bispecific decision themselves.

Voorhees was not entirely reassured. He drew a contrast with the comparatively rapid community adoption of anti-CD38 antibodies such as daratumumab (Darzalex; Johnson & Johnson) in frontline therapy and suggested that bispecific antibodies in the front-line setting may integrate more slowly, predicting a widening of access disparities in the near term. One structural barrier the panelists highlighted was that all myeloma bispecifics carry Risk Evaluation and Mitigation Strategy (REMS) requirements, creating a certification and administrative burden that does not exist for bispecific antibodies approved in lymphoma or lung cancer—a meaningful asymmetry that may slow adoption within myeloma specifically.

Community practices may act based on what makes good business sense, Kaur said. Those that adopt frontline bispecifics will retain patients who might otherwise be referred out for CAR T. “They get to keep the patient,” she said, “and then keep their revenue and to support the practices.”

Future front-line pathways may offer more flexibility than the current debate implies, Garfall said. A practice comfortable with daratumumab-based quadruplets or a CELMoD-based induction followed by a bispecific in the second line may achieve outcomes comparable to a frontline bispecific strategy. “As long as you preserve options to switch down the road, patients probably do the same in the long-term,” he said.

Financial Toxicity. Voorhees turned next to the financial dimension of the same trend. Front-line myeloma therapy is already among the most expensive treatment paradigms in oncology; the integration of bispecific antibodies and CAR T-cell consolidation will amplify costs further. How should institutions and clinicians account for that reality when designing treatment pathways?

Garfall made a structural argument: Academic centers need to reinvigorate simple, pragmatic investigator-initiated trials designed to reduce treatment intensity and duration. He expressed concern that the field has ceded the agenda to industry sponsors, who have legitimate risk aversion driven by their development investments and thus favor intensive, long-term regimens. Cooperative group mechanisms, he argued, have become too cumbersome to generate the efficient de-escalation data the field needs.

Fazal redirected attention to financial toxicity at the patient level, not just the system level. He cited data suggesting that a substantial proportion of patients decline or discontinue therapy because of cost.⁵ “I really want to know how many people are not going to take the maintenance therapy for myeloma because of the financial toxicity to them,” Fazal said.

Voorhees articulated what he sees as the most practical near-term mitigation strategy: defined-duration therapy. Finite-course bispecific regimens not only reduce resistance risk but could substantially lower aggregate costs. For CAR T-cell therapy used as front-line consolidation—despite its extraordinary upfront expense—the calculus may work in patients' favor over time. If a single CAR T infusion eliminates the need for years of maintenance lenalidomide, the long-term cost burden may be lower than it appears. That framing recasts high-cost interventions as potentially cost-efficient if they enable treatment-free intervals.

Health Equity Metrics That Matter. Voorhees asked which specific metrics institutions should track to ensure they are delivering early novel therapies equitably across demographic groups.

The key gaps are not disparities within cancer centers but in disparities of access to them, Garfall said. National Cancer Institute (NCI)-designated cancer centers are generally required to monitor the demographic composition of their catchment areas and compare it to their patient populations. “It’s really interesting to look at the demographics of your catchment area versus demographics of your patient population in your center,” he said. “Think about where there are barriers for people in your catchment area don't have access to get into the subspecialty centers.”

Huntsman has an initiative along these lines, Sborov said, as it tracks the proportion of patients being treated more than 50 miles from the cancer center. The data reveal significant geographic reach—but also a population of myeloma patients receiving care far from specialized expertise, whose treatment patterns and outcomes are largely invisible.

Voorhees emphasized 2 additional dimensions that he considers underappreciated. First, the rural-urban divide will produce striking differences in treatment access as bispecifics and CAR T move into earlier lines of care. Second, health literacy operates as a compounding barrier. “You might have a community oncologist who just kind of in passing says, ‘Oh, you should go see this myeloma specialist about CAR T-cell therapy or about bispecifics.’ And they're not going to go. It's a pain; the traffic is a pain. They can't grasp how potentially fundamentally life-changing some of these therapies could be.”

Household income is a key variable, Shah said. In a low-income household, if the patient is the primary wage earner, having flexible scheduling and workplace accommodation is not merely convenient; it’s essential. She also pointed to institutional geography: the location of academic tertiary centers in dense urban cores creates access barriers related to parking, public transit, and navigation, which vary by socioeconomic status.

Parmar raised insurance status as a fundamental equity lever. Even patients without insurance can access CAR T-cell therapy at institutions with robust charity care programs—demonstrating that payer status, while significant, need not be determinative. However, he and Garfall both warned of the impact of expiring Affordable Care Act (ACA) subsidies.⁶

“We’re about to get another wave of uninsured,” Garfall said. “I feel like for a while that problem got a lot better. And now that all these ACA subsidies are going away, there's going to be a lot more uninsured patients out there.”

How Will CELMoDs, Migration of CAR T and Bispecifics Reshuffle the Deck in R/R Myeloma?

For the second nonconsensus discussion, Hansen returned to some of the same questions about geography and underserved communities that were raised in the first roundtable. But as CAR T-cell therapies and bispecific antibodies move into earlier lines of treatment, this second discussion uncovered new issues: Should every patient receive a B-cell maturation-antigen (BCMA)-targeting therapy? Are some patients too frail for T-cell redirecting therapies? If therapies now seen in later-line care are moved to frontline use, how will this affect decision-making at the first relapse?

Participants moved through questions about both therapeutics and policy, taking on antibody-drug conjugates (ADCs), CELMoDs, ocular monitoring barriers, community outreach, equity metrics, and current reform debates.

ADCs and Oral Combinations. Hansen opened by asking panelists where belantamab mafodotin (Blenrep; GSK), selinexor (Xpovio; Karyopharm Therapeutics), and combinations with pomalidomide (Pomalyst; Bristol Myers Squibb) will fit into treatment plans as bispecifics and CAR T are used in earlier lines of care, particularly for patients in underserved communities who cannot travel for T-cell redirecting therapy.

Garfall immediately pushed back. “This is framed a little bit condescending towards these other therapies,” he said. “Pomalidomide and belantamab are potent, effective drugs that I think still have a role, especially if we're thinking about some of the risks of immunotherapies.”

Voorhees reinforced the underlying principle. “Everybody should get a BCMA-targeted therapy at some point in their treatment journey,” he said. And Sborov noted that belantamab-based combinations—particularly in the context of the DREAMM-7 (NCT04246047) and DREAMM-8 (NCT04484623) trials^7,8 —have demonstrated strong efficacy in earlier lines, not merely as late-line salvage.

Sborov acknowledged a particular practical niche: Programs that are not yet comfortable administering bispecifics, or whose patients are unwilling to travel for CAR T-cell therapy, can offer a BCMA-targeted approach with belantamab that is well tolerated when dose adjustments are made thoughtfully. Parmar and Yee agreed, with Parmar noting that both selinexor and belantamab have roles even within academic settings.

In academic centers, Voorhees said belantamab-based triplets are likely to see increased use as patients relapse after BCMA-targeted bispecifics or CAR T-cell therapy, with the presumption that there was a T-cell dysfunction component to their relapse. “So, you're going to have a lot of people coming in with something that doesn't necessarily require good T-cell fitness,” he said. “It will be really interesting to see how that plays out, but that'll be more on the academic side of things.”

He suggested that the US Immunotherapy Consortium could be a vehicle for tracking this pattern systematically. Selinexor and pomalidomide or CELMoD-based therapies, he added, are likely to serve as "bridge" regimens—providing disease control and treatment pauses between courses of bispecific therapy. How these agents are utilized in academic vs community settings, he argued, will diverge significantly.

Ocular Monitoring for Belantamab. As Shah noted, a frequently cited barrier to belantamab use is the requirement for ophthalmologic monitoring to detect treatment-related keratopathy. In rural and isolated communities, access to ophthalmologists—or even optometrists—can be severely limited, complicating administration outside of centers with established eye care partnerships.

Yee described GSK's early-stage work on a "remote eye doctor-in-a-box" approach, acknowledging that while conceptually appealing, it has not yet reached clinical validation. He advocated for a more radical simplification of the monitoring protocol: Reduce the assessment to a single question—blurry vision, yes or no—and hold the drug accordingly. He noted that European practice appears to be moving in this direction.

Encouraging data have come from the Greek Myeloma Study Group, which Voorhees said has developed a system that may enable belantamab administration without any eye specialist involvement.⁹ Instead, it relies on patient-reported symptoms and straightforward visual acuity testing. He emphasized that the validation step—demonstrating safety in a cohort not receiving regular ophthalmologic monitoring—remains necessary, but he called it a potentially transformative advance if successful.

The panel acknowledged several complicating factors: discordance between subjective symptoms and objectively measured keratopathy, significant subjectivity in grading severity (particularly at the threshold between grade 2 and grade 3), and the high prevalence of baseline ocular changes in older patients, including those with comorbid conditions common in myeloma populations. Fonseca, who practices in Florida, said within his patient population, preexisting ocular pathology is extremely common, making baseline assessment essential to distinguish drug-related from preexisting findings.

CELMoDs: Oral Access, but at What Price? Hansen asked the faculty to consider the potential role of next-generation CELMoD agents, notably iberdomide and mezigdomide from Bristol Myers Squibb, which are seen as successors to today’s immunomodulatory therapies.² Can these oral, community-administrable regimens help patients who lack access to bispecifics, CAR T, or ADCs that require specialty monitoring?

Garfall expressed enthusiasm about regimens such as iberdomide-daratumumab and mezigdomide-carfilzomib-dexamethasone (mezi-Kd)², which he suggested could serve as genuinely attractive second-line options for patients with significant access barriers—potentially allowing clinicians to forgo bispecific therapy without meaningfully compromising outcomes. Iberdomide is also being studied with the bispecific elranatamab (Elrexfio; Pfizer). Following these discussions, phase 3 data for the mezi-Kd regimen were released.²

Voorhees elevated a point Kaur had made earlier: Medicare has the authority to negotiate pomalidomide pricing under the Inflation Reduction Act (IRA), and that negotiation could take effect as early as 2027. If mezigdomide carries a substantially higher cost than a newly repriced pomalidomide, the cost differential could influence community prescribing in ways that are disconnected from clinical considerations.

Kaur noted that the $2000 annual out-of-pocket cap under the IRA may blunt the patient-level cost differential between pomalidomide and mezigdomide, complicating the financial comparison. She also argued for a more nuanced clinical differentiation between the agents: Mezigdomide may have particular advantages in extramedullary disease and in that context could be preferred on biological grounds.

Preliminary signals suggesting that newer CELMoDs may carry a lower risk of secondary malignancies compared with lenalidomide, Garfall noted, which could also influence decisions in the maintenance setting.

Community Outreach and Beyond. Panelists were asked what role community outreach can play in reducing attrition among minority patients after first or second relapse. Sandahl emphasized that outreach must extend beyond education for community oncologists to reach patients directly—particularly in lower-income and Black communities, where myeloma incidence is higher but representation in clinical trials and access to later-line therapy remain disproportionately low.

Said Fonseca, who oversees trials in the community setting, “If you have [a higher number of] Black patients, how many of them are really offered this service vs other services? In other words, it's kind of like a quality measure,” he said, referring to a metric that has been part of the Merit-based Incentive Payment System (MIPS) through CMS.¹⁰

Hansen underscored that culturally responsive patient education is essential and that the field has tended to focus on provider education while underinvesting in direct patient engagement.

Asked which metrics institutions should track to evaluate equity in treatment selection—specifically, who is offered CAR T vs an oral, ADC, or bispecific regimen—Voorhees offered a candid observation: “If each of our institutions looked at this today, our more highly educated patients are getting CAR T therapy and our less educated patients are getting other therapies, if I had to guess.”

“Without question,” Garfall replied.

Health literacy, education level, urban vs rural geography, race, and socioeconomic status are all likely to be significant determinants of what therapy is offered—and what patients ultimately accept. Yee expressed caution about rigid institutional metrics, noting that mandated quality measures have a history of producing unintended consequences that can harm the patients they are intended to help.

When should real-world evidence be used to identify clinical appropriateness? Hansen said Moffitt is using social determinants of health indices—including the Area Deprivation Index and Social Vulnerability Index—to characterize the access landscape of their patient population. The median distance from a patient's home to the Moffitt campus was approximately 70 miles, a figure that itself signals significant access pressure. “Using these types of studies to really see what are some access barriers that might impact what therapy some of these patients might receive is going to be very important,” she said.

How Policy Drives Decisions. Finally, Hansen asked the panel to address national policy changes to ensure that therapeutic choices among the many options in multiple myeloma are “driven by tumor biology and patient preference rather than financial or geographic constraints.”

For Garfall, many of the treatment choices are distorted by arbitrary payment differentials in reimbursement structures—and neutralizing those differentials would meaningfully change prescribing behavior. Parmar pointed to drug pricing as the central lever, noting that government negotiating power, when exercised, can produce real change.

Voorhees offered a measured assessment of the IRA, acknowledging that pharmaceutical industry influence may have limited the law's potential impact while still affirming the importance of revisiting and refining it. He also highlighted a narrower but practically significant policy gap: the limitations on lodging reimbursement for patients receiving outpatient CAR T monitoring at academic centers.

“So, there are certain lodgings that will be accepted, certain that are not,” he said. “Opening up the options for patients and providing financial resources to allow those things to happen, I think, is important.”

References

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3. Raab MS, Weinhold N, Kortüm KM, for the GMMG-HD10/DSMM-XX (MajesTEC-5) investigators. Teclistamab-based induction treatment in transplant-eligible, newly diagnosed multiple myeloma: a phase 2 trial. Nat Med. Published online June 25, 2026. doi:10.1038/s41591-026-04471-x
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7. Hungria V, Robak P, Hus M, et al., for the DREAMM-7 study investigators. Belantamab mafodotin plus bortezomib and dexamethasone in patients with relapsed or refractory multiple myeloma (DREAMM-7): updated overall survival analysis from a global, randomised, open-label, phase 3 trial. Lancet Oncol. 2025;26(8):1067-1080. doi:10.1016/S1470-2045(25)00330-4
8. Dimopoulos MA, Beksac M, Pour L, et al., for the DREAMM-8 Investigators. Belantamab mafodotin, pomalidomide, and dexamethasone in multiple myeloma. N Engl J Med. 2024;391(5):408-421. doi:10.1056/NEJMoa2403407
9. Terpos E, Trudel S, Mateos MV, et al. Practical guidance on clinical management of belantamab mafodotin-associated ocular events. Am J Hematol. 2025;100(10):1839-1850. doi:10.1002/ajh.70015
10. 2025 MIPS Quality Measures. MD Interactive. Accessed June 27, 2026. https://mdinteractive.com/2025-mips-quality-measures