Dr Maakaron on Choosing Between Bispecific Antibodies and CAR T-Cell Therapy in DLBCL

Joseph Maakaron, MD, assistant professor, medicine, Division of Hematology, Oncology, and Transplantation, the University of Minnesota Medical School, discusses factors that influence his decision to use bispecific antibodies or CAR T-cell therapy in patients with diffuse large B-cell lymphoma (DLBCL).

Patients with DLBCL and central nervous system (CNS) metastases may derive more benefit from CAR T-cell therapy than bispecific antibodies, as more data have been published supporting the use of the former in this population, Maakaron says. For patients who do not have CNS disease, the decision between the 2 drug classes can often be personalized based on patient preference, Maakaron notes. For instance, many patients prefer CAR T-cell therapy because it is administered as a single infusion and requires less of a time commitment than treatment with bispecific antibodies, Maakaron explains.

However, for patients who are elderly or have several comorbidities, such as heart disease, bispecific antibodies may be the optimal treatment approach, Maakaron emphasizes. These agents are administered over multiple cycles. Each treatment plan begins with ramp-up dosing, which serves as an introductory stage where patients receive low doses of the agent to try to avoid associated toxicities, according to Maakaron. Furthermore, most patients who are eligible for bispecific antibodies will require a short hospitalization period for the first few doses, meaning they can receive treatment in a controlled environment, Maakaron says. This hospitalization period allows oncologists to estimate how a patient might fare as they continue treatment in the outpatient setting, Maakaron notes.

Secondary malignancies that develop from CAR T-cell therapy are sometimes a concern, Maakaron adds. For instance, a published case study described 1 patient who had diarrhea after CAR T-cell infusion and was subsequently diagnosed with a T-cell malignancy in their intestines, Maakaron explains. Although these secondary malignancies are rare, the attention that the medical community has paid to them recently may make hematologists hesitant to use CAR T-cell therapy, Maakaron says. Data regarding the risk of secondary malignancies after treatment with a bispecific antibody are not as robust, Maakaron notes. Unlike CAR T-cell therapy, bispecific antibodies do not leverage genetic modification and do not require lymphodepleting chemotherapy, he adds. Therefore, the risk of developing secondary malignancies with bispecific antibodies may be lower than that with CAR T-cell therapy, if not nonexistent, Maakaron concludes.