Outpatient Models Boost Cost-Effectiveness of CAR T and Bispecific Therapy in Multiple Myeloma: Emilie Aschenbrenner, PharmD, BCOP

At a recent Institute for Value-Based Medicine® event, Emilie Aschenbrenner, PharmD, BCOP, described how Froedtert Health and the Medical College of Wisconsin have developed outpatient-based care models to improve the cost-effectiveness of chimeric antigen receptor (CAR) T-cell therapy and bispecific antibodies for relapsed/refractory multiple myeloma. Aschenbrenner, a hematology coordinator–clinical oncology pharmacist at Froedtert Health and the Medical College of Wisconsin in Milwaukee, noted that leveraging 340B status and a robust infrastructure, the institution delivers lymphodepletion chemotherapy and CAR T infusions in the outpatient setting, with standardized follow-up and patient housing within a 45-minute radius to avoid prolonged inpatient stays. Similar strategies are used for bispecific T-cell engagers such as teclistamab (Tecvayli; Janssen Pharmaceuticals) and talquetamab (Talvey; Janssen Biotech), including compressed dosing schedules with physician visits on treatment days and interim in-person or virtual follow-up to minimize hospital admissions and enhance patient satisfaction.

Regarding trispecific antibodies, Aschenbrenner noted early concerns about heightened immunogenicity and toxicity but said emerging trial data suggest toxicity may be manageable, allowing care pathways to parallel those for bispecifics while maintaining initial caution and provider reeducation. These agents may also help overcome resistance and antigen escape, potentially moving into earlier lines of therapy.

To address disparities in access—particularly for rural or underserved populations—she emphasized the importance of standardized processes, collaborative partnerships, and shared care models. For example, Froedtert’s collaboration with ThedaCare aims to extend advanced therapies and consistent treatment protocols to a broader, more diverse patient base across Wisconsin.

This transcript was lightly edited; captions were auto-generated.

Transcript

With novel therapies significantly impacting the management of relapsed/refractory multiple myeloma, what innovative care delivery models can be implemented to improve the cost-effectiveness of using CAR T-cell therapy and bispecific antibodies?

We were fortunate to talk about this in our panel, in the multiple myeloma panel, with my colleagues on the previous panel. We have a pretty robust infrastructure at Froedtert in the medical college. I also had some prior panelists that work with Mayo Clinic. We're all able to offer so many steps of those therapies in our outpatient infusion center, and the patients have very routine, standardized follow-up. This is more cost-effective to the health system.

We're a 340B institution, for example, so we're able to give these therapies and have that be more cost-effective for our organization. [We will] give the lymphodepletion chemotherapy outpatient, for example. Then we'll give CAR T-cell therapy, and patients will have routine daily follow-up and stay within that 45-minute radius of our campus.

We've also implemented this with our bispecific T cell engagers. When we look specifically at our bispecific T cell engagers like teclistamab and talquetamab, which we've used quite commonly in the penta-refractory setting, we're able to come up with models outside of toxicity to try to give these agents. For example, [we’ll give] teclistamab on a Monday, Wednesday, Friday setting and compress that interval if the patient doesn't have toxicity, so they can be seen by a physician on the days of treatment and then have follow-up, either in person or a virtual visit, on the days in between and in the interim, so that they're closely followed and don't have to be admitted to an acute care setting. Those are ways that we've managed those types of therapies and improved patient satisfaction. Even if they can't sleep in their own bed at home within that 45-minute to an hour radius, they don't have to be sitting in an acute care setting for days to weeks.

As trispecific antibodies enter the landscape, do you anticipate meaningful differences in how they will be implemented compared to bispecifics—particularly regarding toxicity management, care setting, or infrastructure requirements?

I think there was some concern—they're still early in clinical development. We talked about a couple specifically in clinical development, [such as] the one by J&J [Janssen], for example, that targets multiple antigens. As a clinical pharmacist, something we think about is [whether] these [are] more immunogenic. Do they have a more robust immune response? Are the tools we use for education and teaching and implementing outpatient pathways going to be able to be applied to trispecifics, or will there be a heightened immune response or more CRS [cytokine release syndrome], for example, where we're going to have to take a step backwards a little bit and make sure we observe these patients in a more acute care setting, and have a little bit of heightened awareness of these toxicities? Again, reeducation with our urgent care or ED [emergency department] providers.

What we've seen and are discussing with a couple clinical trials with my physician colleagues [is that] fortunately I think some of the toxicities we anticipated may not be quite as severe, so we might be able to parallel our bispecific pathways with these agents. But again, when anything's new, like a new novel therapy, there's always [a need to use] a little bit of caution with those. We're excited because maybe these can overcome some of the resistance and antigen escape, so that patients will have more robust responses, and potentially these could move up in lines of therapy.

What strategies can be employed to mitigate disparities in access to advanced therapies for patients treated in community settings or underserved regions, particularly where clinical trial participation or specialty centers are limited?

We know that there are some disparities in reaching those patients for clinical trials at an academic center, but really a heightened awareness of [whether there are] guidelines and more standardized processes we can have where we can share instead potentially warm handoffs from institution to institution, where we're working more collaboratively. For example, our health system, Froedtert Medical College, is now a partner in a collaborative health system with ThedaCare, so perhaps we're able to standardize some more processes so we can offer those to a wider range and more diverse patient population, especially in our state, also being a very rural population.