How Transplant, CAR T, and Bispecifics Fit Into Myeloma Care: Mansi Shah, MD

As chimeric antigen receptor (CAR) T-cell therapies and bispecific antibodies gain expanded approvals in multiple myeloma, clinicians face increasingly complex decisions about how and when to use these options alongside traditional stem cell transplant.

Mansi Shah, MD, clinical director of multiple myeloma at Rutgers Cancer Institute, explains how evolving evidence and patient characteristics influence treatment sequencing. Shah notes that while transplant remains a frontline standard, CAR T offers a “one and done” option in certain relapsed cases, and bispecifics may be accessible for frailer patients unable to tolerate more intensive therapies.

Check out the first installment of this interview, where Shah discussed the challenges limiting bispecific uptake.

This transcript has been lightly edited; captions were auto-generated.

Transcript

When considering stem cell transplant vs CAR T or bispecific therapies, what key factors influence the clinical decision-making process?

A couple of things. Right now, CAR T is approved for second line and beyond, bispecifics are approved for after fourth line of treatment—so really for fifth line—, and stem cell transplant is typically being used first-line as consolidative therapy after induction treatment.

Right now, they're approved in different settings. I think as the approval settings change, the therapies might evolve in terms of their effectiveness. CAR T therapy does give a plateau; it's one and done, but it's a very high upfront cost compared to a stem cell transplant. Bispecifics right now are approved for ongoing treatment; it's not time-limited, so I do still think transplant is something that is an important tool in terms of salvage or when a patient relapses.

Using a stem cell transplant is not necessarily the tool that I would use in someone, especially who has disease progression after or within 2 years after a stem cell transplant. For someone who is functionally high risk, I would think about doing CAR T as a salvage option or the next-line option vs a stem cell transplant.

What is the standard sequence of treatments for patients eligible for stem cell transplantation?

Typically, in the first-line setting, for patients who are eligible for a stem cell transplant, they should get the stem cell transplant unless they don't want it, or they have comorbidities or other medical conditions that prevent them from getting the stem cell transplant. In that situation, I would think of CAR T or even bispecifics or other clinical trials to use these novel therapies earlier in line than they are currently approved right now.

The way I think of eligibility for patients is someone who is frail or has a poor performance status would be eligible for a bispecific, but they might not be eligible for CAR T or an [autologous] transplant. In terms of tiering, I think of everyone being eligible for bispecifics, less people being eligible for CAR T, and even fewer people being eligible for an autologous stem cell transplant because of the potential side effects. You need to convince me that someone is not a CAR T or a bispecific candidate, but I can see where people might not be an autologous stem cell transplant candidate.