Physician Dana Farber Cancer Institute Boston, Massachusetts, United States
Introduction: BCMA-directed T cell engager therapies (TCE), chimeric antigen receptor (CAR) T cells and bispecific T cell engagers (BiTEs) have shown remarkable efficacy in relapsed/refractory multiple myeloma (RRMM) leading to the approval of idecabtagene vicleucel, ciltacabtagene autoleucel and teclistamab by the FDA, EMA and other regulatory agencies. We performed a global survey on accessibility, practice patterns, and toxicity management of commercially available TCE therapies.
Methods: Clinicians attending the IMS Immune Effector Cell Therapies in Multiple Myeloma Workshop (Boston, USA 2023), in-person or virtually, completed an online survey available for 30 days.
Results: 87 clinicians from 16 countries (North America 64.4%, Europe 25.3%, Asia 6.9%, Australia 3.4%) completed the survey, most practicing in academic practice (86%), in an urban environment (89%). 77% reported CAR-T cell therapy was approved in their country with 44.8% treating 1-5 patients and 14.9% treating >5 patients per month; 67% reported BiTE therapy was approved in their country with 14.9% treating >5 patients per month. Of evaluable responses (n = 40), 62% administered CAR-T therapy inpatient and 15% administered CAR-T therapy outpatient ≥ 50% of the time. Length of time between decision to treat with CAR-T therapy to infusion was 6-12 weeks for 42% of responders and < 6 weeks for 20%. Most (75%) reported inpatient administration of BiTE therapy step-up dosing; 17.5% reported outpatient step-up dosing administered ≥ 50% of the time. 53% prefer cilta-cel, while 23% reported CAR-T therapy preference depended most on patients’ co-morbidities (89%), timing of next available apheresis (67%) and age (56%). Maintenance therapy after CAR-T therapy was reported by 25% and 5% of respondents in 1-10% and 11-50% of their patients, respectively, to “maintain level of response achieved” (50%) or “achieve a deeper level of response” (25%).
Tocilizumab was used as cytokine release syndrome (CRS) prophylaxis by one responder (2.5%) due to history of prior CRS. Keppra neurologic prophylaxis was used by 47.5% and 15% of responders for CAR-T and BiTE therapy, respectively. Delayed neurotoxicity with CAR-T was reported in 1-5% of patients by 57.5% of responders and 6-10% by 15%; most common manifestations were other movement/neuromuscular disorder (62%), nerve palsy (55%), and Parkinsonism (45%). Infectious prophylaxis included HSV (92.5%), PJP (90%), bacterial pathogens (55%), fungal pathogens (60%), and IVIG (77.5%). Most respondents (46.3 – 86.5%) reported completing an infectious work-up including CMV, EBV, Hep B/C, and HIV. However, 87.5% have not treated an HIV+ patient with CAR-T therapy due to lack of available data or patient need.
Conclusions: Trends of TCE use and supportive care in MM vary widely among academic centers across the globe, demonstrating a need for further understanding of disease and toxicity management among the international myeloma community, along with improved access beyond urban centers.
