Optimizing the Use of Bispecific Antibodies in Myeloma and Beyond: Awareness of AEs

In this episode of OncChats: Optimizing the Use of Bispecific Antibodies in Myeloma and Beyond, Saad Z. Usmani, MD, MBA, FACP, FASCO, of Memorial Sloan Kettering Cancer Center, and Tarun Wasil, MBBS, FACP, of Northwell Medicine, discuss the challenges and strategies in managing bispecific T-cell engagers in the realm of cancer, emphasizing the importance of community and tertiary care collaboration to handle unique toxicities like cytokine release syndrome (CRS) and the need for well-defined protocols to ensure patient safety and effective treatment.

Wasil: I think there’s one T-cell engager that’s already approved for small cell lung cancer and a lot more are being studied in prostate cancer, bladder cancer, and many others. As you said, [we need to be mindful of] the unique toxicity of CRS, immune effector cell–associated neurotoxicity syndrome, and [other] infections. Community physicians, and even the patients, get a little bit [nervous] about safety. Safety is the main concern here, and that’s why I think that collaboration between the tertiary care center and the community centers is of the utmost importance.

I know that right now, we are sending patients to you, at Memorial Sloan Kettering Cancer Center, or other tertiary care centers, to give the ramp-up dosing, which is the most important time when patients can develop CRS. It’s quite predictable; usually, most of the CRS happens after the first or second ramp-up dose, and sometimes, the third ramp-up dose. As such, that is the crucial period when patients get admitted. [Those at] tertiary care centers have a lot more experience and are the ones that can manage these effects.

But I will ask you, what kind of policies and procedures can we put into place in the community setting so that we can take some of the workload [off of you and still] keep the patients safe? I think this is one of the areas that is going to expand very fast and by a lot. So, we need guidance in this field.

Usmani: I agree with you. I think this initial ramp-up period is very important; this is where one can see CRS, and many times, this is just a fever, and that fever can be managed with acetaminophen. If the fever occurs again, we have to think about how the patient needs to be brought in, managed closely, and be given tocilizumab [Actemra].

The initial approvals [of these agents] came with in-patient monitoring but what we are realizing now is that not every patient needs that. If you have patients who have good performance status; who live reasonably close by, so within half an hour; and have good social support, you can start them in the outpatient setting and provide them with guidance to call and come into the hospital so that they can receive tocilizumab [if they experience CRS]. This is where I think [it’s important to have] a good collaboration with the health care system that you are engaged with and making sure that their emergency room has the algorithm in place so that when these patients come in, they know exactly what to do. They can give them dexamethasone, they can give them tocilizumab, and monitor those patients. For the most part, [patients would undergo] observation for maybe only 23 hours, and then go home after that.

Once CRS happens, it typically doesn’t happen again. Recurrent CRS is very rare, and so, having those kinds of mechanisms in place will help. The patients you have to admit are the ones who are really sick, who have a high burden of disease; it’s better to monitor those patients on the in-person service side, and there, too, you have to apply the same algorithms. I think [this becomes] more of an education of the emergency room physicians and staff and making sure they have those algorithms in place, as well as the in-patient team that’s going to be taking care of patients. This can be created in a very nice manner, [by] looking at [and leveraging] bispecific SOPs.

As we get more bispecifics, the patterns of CRS and infection risk will be different for different [agents]. But at least for the CRS management part, I think it will be straightforward; it can be applied to any product. When it comes to prophylactic antimicrobial coverage, so use of intravenous immunoglobulin potentially or the use of growth factors, it will depend on the product.