Scaling Innovation in Advanced Multiple Myeloma Care Delivery: A Q&A With Ameet Patel, MD

Multiple myeloma was once viewed as an incurable diagnosis, but Ameet Patel, MD, of Florida Cancer Specialists & Research Institute, explains that modern therapies now offer patients hope for a potential cure. Speaking at the recent Institute for Value-Based Medicine® event in Tampa, Florida, titled “Pioneering the Next Era of Oncology Care,” Patel participated in the critical panel discussion, “Scaling Innovation: Delivering Targeted Therapies, CAR T, and Bispecifics in Multiple Myeloma.”

In this interview with The American Journal of Managed Care® (AJMC®), Patel explores the practicalities of delivering advanced therapies like chimeric antigen receptor (CAR) T-cell therapy and bispecifics. He provides a detailed look at the factors guiding the choice between inpatient and outpatient delivery, addresses the significant operational and financial challenges institutions encounter when implementing these treatments, and shares vital strategies for securing payer approval and ensuring equitable access to these life-saving innovations for all patients. His insights offer a comprehensive roadmap for navigating the rapidly evolving landscape of multiple myeloma care

This transcript was lightly edited for clarity.

AJMC: For context, can you briefly compare targeted therapies, bispecifics, and chimeric antigen receptor T-cell therapies for multiple myeloma in terms of their efficacy and safety profiles?

Patel: To your point, I think this exemplifies how innovative this space has been for multiple myeloma. When I was in training, we talked about multiple myeloma as an incurable disease, but now we have cellular therapeutics that have proven, over long follow-up times, that patients can, in fact, be cured with some of these therapies.

Targeted therapies, to distinguish from cellular therapies, are either oral- or immuno-drug conjugates that we utilize in a chronic or administrative fashion to be able to keep people's disease in remission, whereas in CAR T-cell therapies, for example, we are talking about giving patients an infusion after lymphodepleting chemotherapy to be able to eradicate any residual or active multiple myeloma cells in somebody's body.

What we find is that there's a big proportion of individuals who are actually long-term cured and no longer need any kind of chronic treatment, which is a completely different paradigm from what we're used to in multiple myeloma. This is in contrast to bispecific therapy or T-cell engagers, where, much like CAR T-cell therapy, we utilize T cells to try and attack multiple myeloma cells. Instead, we utilize a drug to be able to infuse these therapies over time. In graded infusions, these T cells in a patient's body become more engaged to eradicate multiple myeloma cells, and we're seeing great efficacy in there, as well.

AJMC: Which treatments are best suited for inpatient vs outpatient delivery, and what factors guide that decision?

Patel: Ultimately, it comes down to logistics and access for patients. In CAR T-cell therapy, we infuse these CAR T cells with the expectation that there are toxicities that may require hospitalization. Close proximity to hospitals is important due to the severity of adverse effects that may occur for patients, but overall, if these adverse effects can indeed be manageable, and as patients are able to get through those with close observation by their provider and their cell therapy team, we find that a lot of patients don't require any further chronic therapy directed toward their myeloma.

Ameet Patel, MD | Image Credit: © Florida Cancer Specialists & Research Institute

That lends itself very well to a hybrid approach of outpatient and inpatient treatment, where patients can get their treatment on an outpatient basis. They're monitored very closely. There may be a remote monitoring system involved. If necessary, based on symptoms or lab parameters, a decision can be made to manage those adverse effects in a hospital setting, as well.

This is in contrast to bispecific therapy. To the largest extent, after they go through their induction phase, patients are able to manage most of their therapy as an outpatient. Bispecifics, in the first several doses for a patient, people can experience immune activation, like cytokine release syndrome or neurotoxicity. For those reasons, oftentimes, by package insert or indications by trials, patients require very short hospitalizations.

So, it's a conversation at a patient and provider level to decide what is logistically more feasible for patients and what is best mirrored by their quality of life and their goals of care.

AJMC: What operational and financial challenges do institutions face when scaling advanced therapies? For example, staffing or therapy costs?

Patel: Bispecific therapy, tackling the operational component, requires a dedicated team to be able to follow these patients. Education is key, so making sure that these patients also have the right support at home in the event that adverse effects do occur. It requires 24-hour support from providers to be able to carry patients safely through these kinds of therapies.

Thankfully, a lot of these patients who receive bispecific therapy tend to do pretty well with the right operational infrastructure, whereas in CAR T-cell therapy, you require a more dedicated system by virtue of the acuity of adverse effects that may occur in the first 2 weeks of treatment.

Although a lot of patients can initially be followed outpatient very closely daily, some individuals need to be in close proximity to a hospital setting to ensure that their symptoms can be very well managed. That requires a dedicated inpatient and outpatient team for collaboration purposes.

AJMC: What strategies have proven effective for securing payer approval for these therapies, and how can institutions ensure equitable access for all patients?

Patel: When it comes to the payer component, I always recommend that it start with a discussion and education. What are the needs within the community, and how can we best help patients?

From a financial standpoint, it's important for both practices and institutions to decide if delivering this therapy is an area of high unmet need for their patients. Based on that agreement, it very well falls into place the opportunity to be able to operationalize and deliver these types of innovative therapies locally.

Now, on the comment about CAR T-cell therapy, this is a rapidly and growing space, and what we're finding is that this is becoming increasingly deliverable within the community setting. That requires not only grounds for certification but also ongoing conversations with payers to ensure that proper quality standards are met and that the infrastructure can be invested in to be able to safely deliver these therapies.