Care Teams Ease Inpatient/Outpatient Transitions in Multiple Myeloma

THE PATIENT WITH multiple myeloma often faces a complex journey involving multiple lines of therapy that can last decades. It is a complicated landscape, which is fraught with insurance coverage challenges and often requires multiple providers and settings and care coordination. The development of comprehensive care plans is conducive to optimal care.

Autologous stem cell transplantation remains a standard of care for a majority of patients in first remission since the 1980s. As a result, community oncologists have fostered relationships with academic oncologists and transplant partners to deliver this care. These multidisciplinary partnerships are essential, especially given the emergence of novel cellular therapies such as chimeric antigen receptor (CAR) T-cell therapy and bispecific antibodies, with their unique logistics and toxicities that span the entire treatment journey.¹

“The collaboration between the community oncologist and other specialists throughout the continuum of care for the patient with multiple myeloma can serve as a framework for other disease settings,” Jesus G. Berdeja, MD, director of myeloma research at Tennessee Oncology said during an interview with Targeted Therapies in Oncology.

As both classes of agents lead to the activation and expansion of T cells, they are associated with unique and serious toxicities, including cytokine release syndrome (CRS), immune effector cell (IEC)–associated neurotoxicity syndrome (ICANS), and delayed neurotoxicity. In addition, IEC–associated hemophagocytic lymphohistiocytosis (HLH)–like syndrome, which exhibits overlap between CRS and HLH, can be challenging to diagnose and treat.²

The use of CAR T cells is somewhat more complicated than bispecific antibodies. “Overall, delivering CAR T-cell therapy requires a specialized center in which clinicians are familiar with the therapy’s safety profile,” Berdeja said. “But even in that space, the community oncologist eventually takes over care of the patient.

“For smaller-size practices, it might be impractical to consider CAR T-cell therapy, but that is not the case with bispecific antibodies. Practices may choose to partner with an academic center or a local hospital during the initial phase of bispecific antibody therapy,” Berdeja suggested.

Berdeja also emphasized the duality associated with adverse events and bispecific antibodies. “The initial step-up dosing and the first cycle is when the patient is more likely to experience [signs of] CRS or even neurotoxicity,” Berdeja said.

But that toxicity dissipates over time. To mitigate CRS, oncologists can prescribe tocilizumab (Actemra) and steroids, whereas treatment for ICANS includes steroids and anakinra (Kineret) in severe cases. Management of cytopenias and infection is similar to post–hematopoietic cell transplantation strategies with the availability of antimicrobial prophylaxis, growth factor support, immunoglobulin replacement, and vaccinations.²

Tennessee Oncology, Berdeja’s practice, employs more than 100 oncologists and uses 30 clinics. Administrators have developed 3 specialty clinics that provide support for patients who are treated with CAR T-cell therapy and bispecific antibodies. The clinics are located longitudinally across the state from east to west. Patients undergo CAR T-cell therapy in those clinics and, once completed, can return to their home clinic.

“Tennessee Oncology is able to carry this out without having to partner with a separate academic center,” Berdeja said. “But it does require partnerships with local hospitals that have an inpatient unit that can treat acute patients.”

Practices interested in providing this level of care will need to install the needed infrastructure to ensure clinic access and coverage 24/7. “These toxicities don’t always occur during working hours,” Berdeja said. “As the use of bispecific antibodies expands to solid tumors, the need for these types of specialty clinics will continue. I think practices will start figuring out what works best for them,” Berdeja added.

Challenges With Bispecific

Antibodies

Berdeja emphasized some challenges to using bispecific antibodies. As these agents were only approved in 2022, many community oncologists do not have much clinical experience with these agents unless they were involved in the clinical trials. Although the adoption of bispecific antibodies has been somewhat delayed, much of the delay might be due to the inexperience factor, Berdeja noted.

The other challenge associated with these agents is that the FDA requires risk evaluation and mitigation strategies (REMS) programs to be in place. REMS programs are only in place for patients with multiple myeloma; other cancer types do not always require them. The REMS programs require provider training on CRS and neurotoxicity risks and the completion of an enrollment form for the patient.

“We need to provide more education and training to try to demystify these challenges, in particular CRS,” Berdeja said. “We need to emphasize that CRS is not a continuous adverse event and only arises with step-up dosing.”

Developing best practices to ensure the seamless transition of care, particularly during the handoff phases between community centers and academic centers, is paramount. The patient benefits when there is a strong working partnership between academic and community settings. In the community setting, where only a few hematologists may be REMS certified for bispecific antibodies, collaboration with academic cohorts becomes crucial.

Community Oncologist Survey

A recent survey of community oncologists fielded by Peers & Perspectives® in Oncology,³ and reviewed by Cristina Gasparetto, MD, a cellular therapy specialist at Duke Health in Durham, North Carolina, demonstrated the challenges and strategies involved in transitioning care between inpatient and outpatient settings, particularly for patients with myeloma.

The survey was distributed via 3 email blasts; a social campaign with posts on Facebook, X (formerly Twitter), and LinkedIn; and house ads that appeared in Targeted Oncology™. It was fielded over a 4-week period from June 13, 2024, to July 13, 2024. Peers & Perspectives in Oncology received 44 responses from a broad range of practicing physicians.

Among the 44 respondents, 16% identified themselves as solo practitioners, 48% had 3 to 10 staff members, and 35% had more than 10 staff members, suggesting the need for robust infrastructure and coordination.

Criteria for patient transitions include improved vital signs, symptom control, and proper patient education (FIGURE 1). Key challenges involve social and economic support, insurance issues, and patient understanding. At Duke Health, strategies such as discharge classes, pharmacist consultations, and telehealth are used to enhance patient education. Gasparetto also stressed the need for better housing and support for patients undergoing new therapies.

The importance of involving the patient’s primary care physician (PCP) in discussions about transitioning care from inpatient to outpatient oncology was also evaluated, with 36.4% always involving the PCP (FIGURE 2). Respondents said involvement with the PCP occurred frequently (27.3%), sometimes (22.7%), rarely (9.1%), and never (4.6%).

The most helpful resources or tools that encourage a smooth transition from inpatient to outpatient oncology care, according to survey findings, are electronic health records (68.2%), nurse navigators or care coordinators (63.6%), standardized transition protocols (54.6%), and patient education materials (43.2%; FIGURE 3).

The decision to determine when a patient is ready to transition from outpatient to inpatient oncology care is based on management of severe adverse events (86.4%), disease progression requiring more intensive treatment (63.6%), patient’s preference or anxiety (25.0%), or other reasons (9.1%; FIGURE 4).

Approved Cellular Therapies

The FDA has approved 2 CAR T-cell therapies in multiple myeloma: idecabtagene vicleucel (Abecma) and ciltacabtagene autoleucel (Carvykti). In March 2021, the FDA approved idecabtagene vicleucel for the treatment of adult patients with relapsed or refractory multiple myeloma.⁴ Ciltacabtagene autoleucel followed in February 2022.⁵ Both agents are BCMA-directed therapies.

The first BCMA-directed CD3 T-cell engager, teclistamab-cqyv (Tecvayli), was approved on October 25, 2022, and a second bispecific BCMA-directed CD3 T-cell engager, elranatamab-bcmm (Elrexfio), gained FDA approval in August 2023.^6,7

The Importance of Sequencing

Berdeja noted that because of the multiple lines of therapy used to treat patients with multiple myeloma, the importance of sequencing can’t be overlooked, especially with the emerging cellular therapies that are now available.

“Because we don’t have a cure for myeloma, patients will cycle through treatments serially. There are some good data about how best to sequence these therapies, but we’re still learning,” Berdeja said. “It’s best to give the therapy that makes sense for the patient and not rely on giving a bispecific antibody, for example, just because it’s available,” he said.

Optimal seamless transitions of care can be accomplished through effective communication and information exchange among the entire care team, including accessing shared electronic health records. Developing protocols and safety plans to address adverse events, involvement of clinical pharmacists, and peer-to-peer discussions can’t be emphasized enough. Overall, collaborative efforts and strategic planning can ensure the patient’s safety and efficient transition of care.

REFERENCES
1. Berdeja JG. Multiple myeloma: a paradigm for blending community and academic care. Hematology Am Soc Hematol Educ Program. 2023;2023(1):318-323. doi:10.1182/hematology.2023000431

2. Liang EC, Sidana S. Managing side effects: guidance for use of immunotherapies in multiple myeloma. Hematology Am Soc Hematol Educ Program. 2023;1: 348–356. doi: 10.1182/hematology.2023000435

3. Kilmurray C. Creating solutions for a 'continual state of transition' in cancer care. Peers & Perspectives in Oncology. April 1, 2024; Accessed November 7, 2024. TargetedOnc.com/link/2791

4. FDA approves idecabtagene vicleucel for multiple myeloma. FDA news release. Accessed November 6, 2024. https://tinyurl.com/53ftdtcy

5. FDA approves ciltacabtagene autoleucel for relapsed or refractory multiple myeloma. FDA news release. Accessed November 6, 2024. https://tinyurl.com/y3ajapd3

6. FDA approves teclistamab-cqyv for relapsed or refractory multiple myeloma. FDA news release. Accessed November 6, 2024. https://tinyurl.com/ypvxws4r

7. FDA grants accelerated approval to elranatamab-bcmm for multiple myeloma. FDA news release. Accessed November 6, 2024. https://tinyurl.com/yjyup9u8