Joseph Maakaron, MD, assistant professor of medicine, Division of Hematology, Oncology and Transplantation, University of Minnesota Medical School, discusses factors that influence his decision to use bispecific antibodies or CAR-T cell therapy in patients with diffuse large B-cell lymphoma (DLBCL).
Patients with DLBCL and central nervous system (CNS) metastases may benefit more from CAR T-cell therapy than bispecific antibodies, as more data have been published supporting the use of CAR T-cell therapy in this population, Maakaron says. In patients without CNS disease, the decision between the two drug classes can often be made on an individual basis based on patient preference, Maakaron notes. For example, many patients prefer CAR T-cell therapy because it is administered as a one-time infusion and requires less time than bispecific antibody treatment, Maakaron explains.
However, for patients who are older or have multiple comorbidities, such as heart disease, bispecific antibodies may be the optimal treatment modality, Maakaron points out. These agents are given over multiple cycles. Each treatment plan begins with a dose escalation, which serves as a lead-in phase in which patients receive low doses of the agent to avoid associated toxicities, Maakaron says. Additionally, most patients who are candidates for bispecific antibodies require a brief inpatient stay for the first few doses, meaning they can receive treatment in a controlled environment, Maakaron says. This inpatient phase allows oncologists to gauge how a patient might fare if treatment continues in the outpatient setting, Maakaron notes.
Secondary malignancies that develop from CAR T-cell therapy are sometimes a concern, Maakaron adds. For example, one published case study described a patient who had diarrhea after a CAR T-cell infusion and was subsequently diagnosed with a T-cell malignancy in the intestine, Maakaron explains. Although these secondary malignancies are rare, the attention they have received recently from the medical community may make hematologists hesitant to use CAR T-cell therapy, Maakaron says. The data on the risk of secondary malignancies after treatment with a bispecific antibody are not as robust, Maakaron notes. Unlike CAR T-cell therapy, bispecific antibodies do not use genetic modification and do not require lymphodepleting chemotherapy, he adds. Therefore, the risk of developing secondary malignancies with bispecific antibodies may be lower than with CAR T-cell therapy, if not nonexistent, Maakaron concludes.
