Individualizing CAR T-Cell Therapy vs Bispecific Antibodies in Relapsed Multiple Myeloma

The faculty discuss how to individualize the choice between chimeric antigen receptor (CAR) T-cell therapy and bispecific antibodies in relapsed multiple myeloma. Prompted by CARTITUDE-1 data showing 1 in 3 patients alive and progression-free at 5 years in a heavily pretreated population, one panelist describes that result as the reason the field started defining the word cure in multiple myeloma and frames the decision as an individualized conversation covering every available option now that CAR T-cell therapy is available in the second line. She reports using CAR T-cell therapy before B-cell maturation antigen (BCMA)-directed bispecific antibodies, citing retrospective consortium data showing significantly lower CAR T-cell efficacy after prior BCMA bispecific exposure, and identifies younger patients with high-risk disease as those she considers doing CAR T-cell therapy for in an earlier line. Patients who are older or frail, or who cannot reach a CAR T center but can receive bispecific antibodies closer to home, are described differently. The panel then groups the decision into patient factors such as comorbidities, dialysis, age, and frailty status; disease factors including pace of relapse, ability to await manufacturing, availability of bridging, extramedullary disease, and functional high-risk disease; and logistical factors including travel, time away from work, and prolonged caregiver support. Distinct toxicity profiles are contrasted for antibody-drug conjugates, BCMA CAR T-cell products, and bispecific antibodies.