Cell Therapy / Resource Centers 07/27/2026

Myeloma Specialists Discuss Treatment Options in Multiple Myeloma Cases

Smiling male doctor in white lab coat with Roswell Park logo, wearing glasses, in a modern medical facility. Marco Davila, MD, PhD Professional woman with dark hair smiling, wearing a black blazer and white top with black embellishments, against a neutral background. Krina Patel, MD, MSc Smiling man with beard wearing a white shirt, professional headshot, suitable for oncology or cancer research content, emphasizing healthcare and medical expertise. Rahul Gosain, MD, MBA Oncologist smiling in white coat, highlighting cancer research and treatment expertise, with a bow tie, in a bright medical setting. Rohit Gosain, MD

Key Points

  • If patients with multiple myeloma relapse after up-front quad-class regimens, second-line and third-line treatment is typically chimeric antigen receptor (CAR) T-cell or bispecific antibody therapies.
  • CAR T-cell therapy is preferably sequenced before B-cell maturation antigen (BCMA)–directed bispecifics, although using bispecifics as bridging therapy while CAR T-cell products are manufactured is appropriate for patients with a high tumor burden.
  • Community oncologists managing patients on bispecific antibodies or after CAR T-cell infusion should monitor for long-term adverse effects and follow prophylaxis guidelines, particularly to manage infection risk.

Reviewing Treatment Options for Multiple Myeloma Cases

Marco Davila, MD, PhD, of Roswell Park Comprehensive Cancer Center, and Krina Patel, MD, MSc, of The University of Texas MD Anderson Cancer Center, joined Rahul Gosain, MD, MBA, of Wilmot Cancer Institute, and Rohit Gosain, MD, of Roswell Park Comprehensive Cancer Center, for the Oncology Brothers podcast Challenging Cases series. The doctors discussed two cases: a patient with early relapse after stem cell transplant (SCT) and an older, transplant-ineligible patient with relapse on maintenance therapy. 

Treatment Options for Patients With Posttransplant Relapse 

The doctors first considered the case of a 48-year-old woman with no significant comorbidities who presented with ongoing back pain and weight loss. Based on imaging, laboratory, fluorescence in situ hybridization, and next-generation sequencing analyses, she was categorized as Revised International Staging System stage III, high-risk multiple myeloma. The patient received daratumumab, lenalidomide, bortezomib, and dexamethasone (Dara-VRd) induction with 2 cycles of consolidation before undergoing autologous SCT followed by daratumumab plus lenalidomide maintenance. However, her myeloma relapsed after 17 months. 

At the time of progression, Dr. Patel would examine light chain levels and kidney function and obtain another PET scan to screen for extramedullary disease or other lesions that may require rapid intervention. At this point, repeating a bone marrow biopsy to test for BCMA expression may not be necessary, although it may be more useful in patients who relapse after BCMA-directed therapies, said Dr. Patel. 

In terms of next treatment, the primary second-line options for relapsed or refractory multiple myeloma are CAR T-cell therapy and bispecific antibodies. Based on current data, CAR T-cell therapy is preferably sequenced before bispecific antibodies, as bispecifics can induce T-cell exhaustion and potentially limit the viability of T-cell collection for manufacturing CAR T-cell products. However, it may be reasonable to use bispecifics after T-cell collection as bridging therapy until the CAR T-cell product is ready, especially if the patient has a high tumor burden and debulking is needed, said Dr. Davila. If using bispecifics for this patient, data from the MajesTEC-9 trial support the efficacy of teclistamab monotherapy in patients previously exposed to daratumumab or another anti-CD38 antibody.

Relapse on Maintenance Therapy

The second case described a 74-year-old man who was diagnosed with immunoglobulin G kappa myeloma 2 years prior. Workup demonstrated standard-risk cytogenetics, but he was ineligible for transplant due to comorbidities including type 2 diabetes, chronic obstructive pulmonary disease, and myocardial infarction. For first-line treatment, he received modified Dara-VRd, achieved a very good partial response after 8 cycles, and continued with daratumumab plus lenalidomide maintenance. After 23 months, he presented with ongoing back pain, and repeat imaging and labs identified evidence of progression. 

In a case like this, the patient’s frailty may hamper the feasibility of CAR T-cell therapy, but it’s still a potential option if comorbidities are well controlled. Selecting between bispecifics and CAR T-cell therapy would require a more in-depth conversation about risks and benefits and the patient’s goals, said Dr. Davila. 

Notably, available data support that BCMA-directed bispecifics are still active after BCMA-directed CAR T-cell therapy. However, a meaningful proportion of patients lose BCMA expression after treatment with BCMA-directed bispecifics, which may compromise the efficacy of subsequent CAR T-cell therapy or other anti-BCMA bispecifics, again supporting the preference for sequencing CAR T-cell therapy before bispecific antibodies. 

Community Perspective

For community oncologists, partnering with larger centers in a shared care model can support offering bispecific antibodies and CAR T-cell therapy to patients with multiple myeloma. Often, referral centers will handle step-up dosing for bispecifics or T-cell collection and CAR T-cell infusion before returning the patient to community settings, particularly if the patient lives far from the referral center. 

When managing patients on bispecific antibodies, oncologists need to monitor for long-term adverse effects such as immunosuppression, cytopenias, and infections. Repeat vaccinations and antiviral, antibacterial, and antifungal prophylaxis are recommended, and intravenous immunoglobulin replacement therapy should be continued as long as patients are receiving BCMA-directed bispecific antibodies.