Relapsed/Refractory Multiple Myeloma: Debate — Contextualizing Safety and Sequencing BCMA-Directed Therapies

The face-off debate continues with the second and third questions, moderated by Dr. Thomas Martin. On contextualizing safety, the CAR T-cell-first perspective stresses preserving T-cell fitness by avoiding prior BCMA-directed exposure when cellular therapy is the intended destination, while the opposing perspective weighs the higher infection risk of continuous bispecific therapy against the practical challenge of recognizing and managing rare delayed neurologic and gastrointestinal toxicities once patients return to the community, underscoring the shared responsibility to educate community colleagues, use IVIG prophylaxis, and de-escalate dosing. The third question addresses sequencing as BCMA-directed therapies move earlier: one side argues that current evidence supports CAR T-cell therapy first followed by a bispecific, citing poorer CAR T-cell performance after bispecific exposure and the availability of alternative targets such as GPRC5D-directed therapy at relapse, while the other side counters that not every patient can access cellular therapy and that clinicians should give the best available therapy at second line rather than withhold a bispecific in anticipation of a future CAR T-cell option. The segment closes on the shared conclusion that patients should receive a BCMA-directed therapy early in relapse, with the choice individualized to the patient, before Round 2 concludes.