Bispecifics in Multiple Myeloma: Transitioning Patient Care to the Community Setting


Expert panelists share insight on transitioning patients on bispecific therapy from an academic or specialty center to the community setting.


Cesar Rodriguez, MD: I want to move on to the next step. We’ve done the step-up dosing. Mayo Clinic did it all outpatient, except for a few that required inpatient. Once the patient is stabilized, we continue outpatient and their care. At Mount Sinai [Hospital], we do the step-up inpatient and discharge them to continue their care outpatient. The CRS [cytokine release syndrome] tends to be within the step-up dosing. We rarely see CRS once patients are on their weekly dosing. We tend to see CRS once patients have been on therapy for a while. In a few circumstances, the patient has an infection or there’s a long break between doses. If the patient doesn’t have an infection or hasn’t had a long pause, they’re more safe to transition care, closer to home, to a community practice, or a local oncologist to continue care. The idea is to try to give treatment closer to where the patient lives and closer to the oncologist who’s normally treating them and to not uproot them completely once we start this therapy.

This is where the next step occurs. Are we ready to say when it’s safe to transition from the institution giving the step-up doses to the community without putting too much burden on the community physician? We’re taking into consideration that a lot of physicians might not be used to seeing patients with myeloma. Hearing about the adverse effects of CRS or ICANS [immune effector cell-association neurotoxicity syndrome] could be overwhelming. One reason is they might not have the staff to dedicate that much time to the patient if the patient is complicated. Another is the cost of having tocilizumab and teclistamab in a clinic. Franny, talk about this transition from the initial institution, where they’re starting treatment, to the community. We have several satellite clinics at Mount Sinai, and we’re transitioning patients to clinics after their first cycle. Are there any particular things that you suggest we pay attention to in this transition?

Frances A. Bell, NP: Once the patient has been tolerating the medication at our main campus here [at Minnesota Oncology] and they haven’t had any major adverse effects or infections, it’s reasonable to transfer the patient to us. We’re 1 of the satellite offices with the training and the nursing staff to monitor, and we know what the parameters are to give the medication. At our institution, once we know we’re going to transition them, because we’re transferring to another Sinai satellite office, we put in for the department change to trigger a new authorization. Then the finance team, within a week, would need to get an authorization for that satellite infusion.

Cesar Rodriguez, MD: That’s a key thing because if you’re transitioning a patient to a different institution or a different clinic, you need a new authorization from insurance. The moment you request the new authorization, the current 1 expires. You need to be careful when you trigger that transition so the patient doesn’t miss a dose. Try to schedule it as soon as they finish—the day after the treatment—to get a whole week head start for that transition. Scott, when does Mayo have a set time for when you deem it safe to transition a patient to a community practice or a satellite clinic?

Scott A. Soefje, PharmD, MBA, BCOP, FCCP, FHOPA: We’ve been transitioning the patient after the full step-up dose. The last dose is the full dose. If the patient has done well, we’ll try to transition them. Particularly if the patient is staying in our downtown campus, we’ll transition them to the other clinic on that next dose.

Cesar Rodriguez, MD: To day 8, or is that the second full dose?

Scott A. Soefje, PharmD, MBA, BCOP, FCCP, FHOPA: It’s the second full dose. It becomes a little more challenging if we’re sending them outside the Mayo system or to 1 of our satellite sites outside Mayo. How are we going to coordinate the transition of care, the different sites of care, and make sure everything happens. Most of our patients have been on Medicare, so that’s easy to do. We send the patient over to make sure the site is ready to accept them.

We’ve gotten pushback from a couple of sites that don’t want to accept the patients because they’re not ready. A couple of other sites are like, “Bring them on. We’re ready to go.” It depends on the site. Then comes coordinating. We’re lucky because we have 1 group of prior authorization individuals that’s in charge of all our health systems and our downtown campus. That group of people is getting good at understanding how long it’s going to take to transition. They may have already started to have conversations with payers before we make the transition: “This is coming. We’re going to be submitting this. It’s a time limited. Are you OK with this?” We’ve been pretty successful in making that transition. It’s not always at the same time. Sometimes it’s on the second or third full dose, or it’s a month later. It’s whenever we can make that transition comfortably and get the patient out of the door.

Cesar Rodriguez, MD: That makes sense. At Sinai, we try to streamline things because I like to be practical. The less work, the better. We’ll do the step-ups in the hospital and transition the patient to our main campus to complete the first cycle. At the end of the first cycle, if they didn’t experience CRS to the last dose and they’re doing fine, then we’ll transition them to satellite clinics or the community. The patient will be transitioned for the start-up cycle too. At that point, there are several reasons for it. We want the flow of the treatment to be good during the first cycles because the first cycle has the biggest impact in terms of response. If there are any complications or cytopenias that we tend to see, it’s going to happen at the beginning. The cytopenias might linger a little more after their step-up dosing. We want to make sure that everything is stable and the patient is tolerating the treatment well, that they’re on acyclovir and Bactrim, and that everything is being tolerated well.

One of the tips that our finance team gave us about this transition process is—at the end of cycle 1 on day 22, when the patient gets their fourth dose—to quickly request the transfer so they can have 1 week to get the approval at the new site. Also, for the finance individuals or those who are requesting the authorization, reach out to the same agent from the insurance because they already have the ball going. It’s going to be a much smoother transition. That way, there won’t be many delays between the end of the first cycle and the beginning of the next dose, which is going to be at the community or satellite clinics. This isn’t financial, but this will have an effect financially if it’s not done properly. Also, [we need to ensure] a good handing off of the patient to the physician who’s going to be taking over that care, to make sure they know what they need to look for or the risk of infections, what labs they need to be monitoring for accounts, for response, and for potential risk of reactivation if patients are having a fever.

Transcript edited for clarity.

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