Dr Sborov on the Use of Ide-Cel and Cilta-Cel in Relapsed/Refractory Multiple Myeloma

Douglas W. Sborov, MD, MS, associate professor, Department of Internal Medicine—Division of Hematology and Hematologic Malignancies; director, Hematology Disease Center and Plasma Cell Dyscrasias Program, the University of Utah Huntsman Cancer Institute, discusses the use of CAR T-cell therapy for patients with relapsed/refractory multiple myeloma.

The multiple myeloma treatment paradigm is rapidly evolving, with frequent new approvals shifting treatment algorithms, Sborov begins. Until April 2024, FDA-approved therapies including idecabtagene vicleucel (ide-cel; Abecma), ciltacabtagene autoleucel (cilta-cel; Carvykti), and bispecific antibodies targeting BCMA and GPRC5D were indicated for patients who had received 4 or more prior lines of therapy. Treatment recommendations typically involved 3-drug combination regimens based on patients’ prior treatment refractoriness, Sborov added. However, the expanded indications for ide-cel and cilta-cel have widened the net of patients with myeloma who are eligible for these products, he notes. Cilta-cel is now approved for patients with relapsed/refractory multiple myeloma after at least 1 prior line of therapy who are refractory to lenalidomide (Revlimid), and ide-cel is now approved for patients who have received 2 prior lines of therapy. These advancements provide more patients with extended treatment-free intervals, including those requiring indefinite myeloma therapy, according to Sborov.

The incorporation of CAR T-cell therapy into earlier lines of therapy could be beneficial for patients with multiple myeloma, as a less heavily pretreated immune system may target cancer cells more effectively, he explains. In his own clinical practice, Sborov discusses the possibility of receiving earlier-line CAR T-cell therapy with all eligible patients due to the therapy’s transformative potential. The earlier-line indications for these products necessitate re-evaluation of existing myeloma treatment algorithms and drug sequencing in the relapsed/refractory setting, he emphasizes. Efforts to refine treatment sequencing strategies are underway and are leveraging both clinical trial outcomes and real-world data, Sborov adds.

When administering CAR T-cell therapy to patients with myeloma, it is crucial to ensure that treatment plans align with patient expectations, Sborov reports. He discusses the entire treatment process with eligible patients, including the workup, time for leukapheresis, manufacturing wait times, lymphodepleting chemotherapy, and CAR T-cell infusion. He also informs his patients that they are required to remain at the Huntsman Cancer Institute for 30 days post-infusion, where they will undergo extended monitoring following the infusion. Sborov also tells patients about potential unique toxicities that are associated with these therapies.

Patient suitability for CAR T-cell therapy is based on age, fitness, disease progression rate, overall disease status, and alignment with personal life plans—considerations that are similar to those for patients undergoing autologous stem cell transplant, Sborov says. Given the availability of BCMA- and GPRC5D-directed bispecific antibodies in later-line myeloma settings, treatment choices often hinge of patient preference, he concludes.