How do you choose which BCMA therapy to use?

So, I think what we have learned, I think in most places that do CAR T transplants have learned, if a person is in real trouble, and by that I mean not just they have high protein levels, but let's say they have poor blood counts, let's say they have very low platelets or their lymphocyte count in their blood is very low, it gets harder to manufacture T cells and then there is a likelihood that that person isn't going to even stay stable enough for the time that it is taking to manufacture the cells. Now a lot of technology is being looked at to try to make those CAR T's faster. Right now the median time, the average time to wait is around four, as long as six weeks but there are technologies out there to try to manufacture them within two weeks or even five days. So if that happens, this will make the choice a little bit easier, but right now for those people who are really needing a treatment and they really don't have a lot of other options, most people I think are going to move them towards a bi-specific because it's just available and faster. And the response rates are in many ways comparable. I think the one thing that makes this choice a little bit easier in some ways is different from lymphoma, where there is clearly a subset of patients who get CAR T therapy who look to all intents and purposes to be cured. That is not the case in myeloma. So even a person going through CAR T, there has not been any what we call plateau. In other words, it doesn't look yet that there's a group of people with myeloma getting CAR T therapy who are going to be cured of their myeloma. So that doesn't mean that, boy, if you had the opportunity to CAR T, it's going to fix everything forever. And I do think that that is maybe something that we have not been as clear as we should to patients about the fact that there are very comparable lengths of time that myeloma can be controlled by CAR T versus by specifics. And so it isn't necessarily one is better than the other yet. I think we're still trying to figure out again what is the best use of all of these. What are the advantages of each type of BCMA-directed therapy? So there are definitely people who are looking at this choice who will say, boy, what I really want is the therapy that gives me a break. And certainly for our patients who get CAR T and those that have been on trials, the fact that you can have a prolonged period of time with no drugs has been marvelous. I mean, I think most people would say that has been great. I think by specifics, like I said, have the advantage of being readily available. And one thing I think we're learning about by specifics, they are currently FDA authorized as weekly injections under the skin. Most people I think are learning that you can probably make that interval a lot bigger, particularly if somebody is responding well, that you won't need to treat them as often. But I do think for people who are looking for quality of life, CAR T really fits that bill. The unfortunate thing if you're a patient is where a lot of the CAR T research is now moving is to introduce drugs after the CAR T, to come up with maintenance strategies. So at the end of the day, you're not going to necessarily be without drugs, but at least for now. That is a very nice break. And the people who are doing well post-CAR T on nothing have certainly loved that. So BCMA is certainly the best target we currently have for myeloma, which means that everybody's seeking the answer using BCMA as their target, whether it's a naked antibody, whether it's an antibody drug conjugate, whether it's a bi-specific, whether it's a CAR T cell. So the question is obviously very germane. CAR T cell therapy has the advantage of being once and done. That is, you go through the process, you may have some toxicities early, but once you get through that early period, you don't need more therapy. And you can go, if you're lucky, years without needing more therapy, and you get to live and not be tied to a treatment center. Bispacifics are on the shelf, and you can immediately get it today, if your insurance authorizes it. And you can get started right away. So if you have a disease that's explosive and you need to get something now, you can't wait. It's certainly better to go with a bi-specific because it's available. Whereas with the CAR T, you have to wait for a slot these days. They're not immediately available. And then there's an engineering time of four to eight weeks, and then finally you get it. So for anybody who needs it immediately, the bi-specific's better. I tend to rule out the antibody drug conjugates because of the toxicity that comes with the drug that's linked. It generally can cause other toxicities. The one antibody drug conjugate directed at BCMA that was available briefly was Bilanthamab mafidotin, and it caused eye toxicity. So I tend to shy away from that. It also wasn't active for very long. And then the naked antibodies haven't been proven yet. So you really are just choosing between a bi-specific or a CAR T, and the differences there are bi-specific immediately available, but it's cumbersome. You need it every week or every two weeks indefinitely. So if you have a CAR T cell, you need to wait for it. It's not immediately available. But once you get it, you're done, and you don't have to keep coming back. So that's sort of the way to choose between those two.