Where Ciltacabtagene Autoleucel Belongs in Sequencing

This opening segment introduces a discussion on ciltacabtagene autoleucel (cilta-cel) in multiple myeloma and frames the questions the program sets out to answer: how chimeric antigen receptor (CAR) T-cell therapy should be sequenced among the available options, and how care can be coordinated across a network spread between referring practices and treating centers. The moderator notes that CAR T-cell therapy transformed myeloma treatment, that it has now moved as early as first relapse, and that clinical trials are ongoing. The first question asks where cilta-cel belongs now that the indication has shifted from patients with 4 prior lines of therapy to earlier relapse and whether the panelists’ referral patterns have moved. The faculty describe an era of multiple immunotherapy options, including CAR T-cell therapy and bispecific antibodies. In the late-line setting, they note that a third of patients are alive and well at 5 years, an outcome not previously seen with a one-time treatment, and state that CAR T-cell therapy should be sequenced before other immunotherapy, consistent with International Myeloma Working Group guidance. In earlier lines, they describe less available guidance. The panel still favors a CAR-first approach, citing healthier and fitter T cells and data indicating that manufacturing CAR-T cells, cilta-cel in particular, earlier in the disease course generally has more product that is in specification.