Joshua Richter, MD, spoke with Marco Davila, MD, PhD, about addressing potential misconceptions surrounding the use of CAR T-cell therapy among those with multiple myeloma, particularly those preventing patients from being referred to a cellular therapy center. They described how factors such as patient age, prior lines or extent of treatment, and the relative convenience of other modalities may prevent patients from receiving CAR T-cell therapy earlier in the treatment course.
Davila is physician–scientist and service chief of the Lymphoma–Myeloma Adoptive Cell Therapy Service at Roswell Park Comprehensive Cancer Center. Richter is associate professor of medicine at the Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, and director of Myeloma at the Blavatnik Family Chelsea Medical Center at Mount Sinai.
Transcript:
Davila: Let’s hit a bit more on this referrer-treatment center relationship. You’re going to be thinking as a community oncologist here. What do you think are the biggest misconceptions that community oncologists still have about CAR T in [multiple] myeloma regarding eligibility, toxicity, or outcomes that are keeping patients with [multiple] myeloma from being referred to a cell therapy treatment center?
Richter: In my mind, there are 2 big ones. One is eligibility, and [the second is] age is just a number. We all have 80-year-old [patients] who are running marathons and 50-year-old [patients] who come in in wheelchairs after a quadruple bypass. I’ve had local doctors say, “Yeah, I didn’t want to refer them because we talked about this patient previously, and they weren’t transplant-eligible, so therefore they’re not CAR T-eligible.” I think that’s still a major misconception that’s preventing some referrers. The other is that I think they’re still under the misconception that CAR T is a last-line or later-line phenomenon, and they wait until they’re triple-class refractory before they send them to people like you and me. I think, as you’ve said a number of times and I couldn’t agree more, the evaluation can be as early as you want. It may not be the time for a CAR T, but earlier evaluation is definitely warranted, and not waiting until the patient is refractory to absolutely everything.
Davila: Yeah. I think there are probably a lot of potential reasons, but for me, the one that may be present a lot is that the alternative seems easy. Whether it’s a T-cell engager, some type of combination chemotherapy, or something like that, it’s just easier. “Is that going well? We can certainly consider cell therapy, but you have to get referred, there’s collection, there’s toxicity, you can’t drive, there’s all these things. Let’s just do a T-cell engager for now, and when you really need it, we’ll figure it out then.” I don’t think that’s necessary. It’s not wrong, and it’s nothing negative on their part. I think it’s just an incomplete understanding of where the field is today, because of how our practices have changed within the last 5 years.
The way we do things today within cell therapy, how quickly we can collect, how we can infuse, do this outpatient, minimize risk, get patients back home—these are things that have happened just in the past few years. Community oncologists are treating every cancer, and they’re having to stay up to date with everything. It’s not a surprise they may not appreciate some of these rapid advances. Some of it doesn’t even have to do with anything clinical; this is operational, [and] this is logistical. Going, “This is a lot of stuff, this is easier…I’ll still get you into cell therapy, but let’s think about this next line.” The practitioner may have 10 or 15 minutes to discuss this with the patient; [they may say,] “Let’s just do something easy.” To me, it reiterates that we just have to make sure all this information gets to patients and referrers about how cell therapy is given today, and how those great outcomes can be achieved with relatively easier processes than there were 10 years ago.
Richter: I couldn’t agree more. It’s a little scary how much you and I agree on things. You know the old saying in myeloma: if you have 2 myeloma doctors, you’re going to have 3 opinions. But we seem to have relatively close to one, which is fantastic.
