In this week's "Ask Dr. Durie" myeloma expert Dr. Brian G.M. Durie discusses CAR T-cell therapy and bispecific monoclonal antibodies and their potential side effects such as immune suppression, increased risk of infection, fatigue, and reduced blood counts.
The BOTTOM LINE: Myeloma patients should weigh the benefits and potential risks of new immune therapies, considering access, side effects, and alternative treatment options, to make well-informed decisions about their treatment journey.
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This week's "Ask Dr. Durie" comes from a patient
who has heard about all of the exciting new immune therapies, particularly the bispecific
monoclonal antibodies and CAR T-cell therapies. The engineered T cells which are used to attack
the myeloma. But her particular question is: this is great,
but what about the side effects of these treatments? The access to these treatments? The difficulties in managing the ongoing issues
with care when you take these wonderful new therapies? And so the first
thing to say is that this
is, in fact, a very important question. These are great new therapies. But, for example, CAR T-cell therapy requires
the T cells to be harvested from the patient and then sent off for manufacturing to be
engineered so that the T cells will, in fact, attack the patient's myeloma. While that is happening, the patient needs
to take what is called bridging therapy. And then once the cells are grown up and ready
for administration, they come back to the hospital a month or s
o later. And so there's a lot of time involved. There are only a certain number of centers
capable of doing this. And so there are access issues. There are a lot of logistic concerns. And then, this is a difficult treatment to
go through. The big, big advantage is that it is what
is called "one and done" in the sense that once those T cells come back and are administered,
then the patient can have a really dramatic benefit on response to therapy and then will
be off therapies. So this is a big,
big advantage. But access to this has been a particular problem
over these last two and three years. Then the bispecific obviously are what are
called "off the shelf". So this means that they are much more readily
available and teclistamab is approved—a BCMA targeted bispecific. But the concern is that with ongoing therapy,
there is a significant risk of suppression of the normal immune system and a risk of
pneumonia, which can be quite serious, as well as other kinds of infection. And linked to
that, fatigue, reduced blood
sugars, blood counts, and the like. And so, not a trivial type of therapy. And so the question is, yes, these are therapies
that are great. But are there other options? And so, the answer to that is yes. And so the important advice is to listen very
carefully to all of the details of the therapies, which might be available in your case, but
also look at information about more standard approaches that are standard approaches for
use in early disease. For example, Dar
atumumab combined with Pomalidomide
and dex (DPd) is a very well-tolerated regimen which can be very effective in the relapse
setting. Even simpler recombinant combinations can
be used in the relapse setting. And so the strong advice I give to patients
is to look at all of these things carefully. This is a time to definitely consider a second
opinion, whether that be live or through a Zoom in some fashion. But talk to your doctor about that and get
all of the input that you need to look at. Yes,
the tremendous benefits of these new
immune therapies. But what is the access? What are the implications for quality of life? What could be the costs to you and your family? And so, the BOTTOM LINE, a very good question,
very, very important phase of the disease in the relapsed setting, too, to look at all
the options and see what are the true pros and cons of these exciting new immune therapies
for.
Comments
Dr. I have a question. I am one and a half years into multiple myeloma. I have been putting off the stem cell transplant. Is this a mistake on my part? I am just not sure what to do. Thank you for all the videos you post. I appreciate it greatly.