Video
How do you do sequencing for CAR-T cell, ADC and bispecific therapy?
Posted by
HealthTree • May 7, 2025
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Description
This video explains how sequencing for CAR-T cel, ADC, and bispecific therapy work.
On this video

Syed Abbas Ali, MBBS, Specialist
John Hopkins Medicine Sidney Kimmel Comprehensive Cancer Center
Transcript
How do you sequence the various types of anti-BCMA therapy? Yeah, so these are excellent questions and I think these are sort of paradigms that we're struggling with right now. There are early studies looking at, such as the Cartitude 2 study, which has a cohort of patients who were previously exposed to anti-BCMA therapy. And what you find is that patients who were exposed previously to anti-BCMA therapy still have a 60% or so response to CAR T cells later on. I think that there are a lot of things that need to be borne in mind over here. I don't think therapies can necessarily be given back to back. I think that there need to be between three and six months between giving such therapies sequentially with each other so as not to disadvantage one after the other. And you can see this sort of reflected in the way that trials used to be initially. Trials would say that we cannot have any prior BCMA therapy if you're going to come on to our trial for BCMA therapy. But over time that was liberalized because there were data that suggested that perhaps this can be done so long as you leave a reasonable amount of time in between the therapies. How do you sequence them is a function of a number of things. One of those is simply the logistics. Bi-specific T cell engagers or bi-specific antibodies are generally more readily accessible. You do not have to go through a process of pharesis. Some CAR T cell products require eight weeks of manufacturing before they return to the patient. And in those eight weeks you have to make other arrangements, especially if the patient's disease is progressing. But sometimes if you don't necessarily have the time or your patient is not necessarily in a robust enough situation or you don't have access to a CAR T cell slot, you may be able to get to a bi-specific antibody sooner rather than later. However, bi-specific antibodies such as the ones that target BCMA do come with drawbacks. For instance, they still can cause CRS. They still can cause significant infections. There are studies showing that perhaps up to three quarters of people on some products might get infections. So it is challenging to do these in the outpatient setting in smaller community settings. So patients may still be committed to having to come to an academic setting to get their bi-specific antibody. And they may need to come every week to get a bi-specific antibody. With CAR T cells that may be different. Maybe the risk of CRS is higher. But you may have a single instance or a longer period of time perhaps where you are involved. And later on you can be monitored. But I think that these therapies can be given one after the other. I think whether you go with one or the other has a lot to do with the logistical aspect of things rather than scientific basis for based on the data as to which one we should do first. Yeah, that's a great question. And one that often isn't a luxury that a patient or the provider can choose. Because as I think your audience well knows, it takes time to manufacture CAR T cells. And there's also availability. So it has been a very nice thing since November to now have an option of a bi-specific to be able to reach to right away, particularly if a person is in a lot of difficulty from their myeloma. I think there has been actually publications back and forth. Whether sequencing worsens response to one or another. Certainly there has been data presented with bi-specifics about using them after CAR T that look reasonable. There was a study presented at ASH by what's called the Consortium for Myeloma Cellular Therapy. And they actually presented some data that was a little bit concerning. And this is basically people who are on trials but who had these individuals had a bi-specific before CAR T therapy and didn't look like it worked that well. Their response that is to CAR T. Now you don't know much about those patients. They really didn't have a lot of specifics. The bottom line is sequencing is still under investigation. And particularly as these therapies get moved up to people who are newly diagnosed, I think that may raise some real questions. But a lot of times the bottom line is I think it's a question of availability. Certainly the one, the target other than B cell maturation antigen or BCMA that seems to be farthest along is GPRC5D, which is the target for the bi-specific telketamab. And it does appear when they've looked at patients who received that bi-specific who have had BCMA-directed therapy previously, the response rates are quite good. So I think you're going to see more of that using different targets with different agents. Now there is even a GPRC5D CAR T cell that was published about a couple of months ago. So that may be something else. One of the things that has been presented in terms of sequencing is sequential CAR T. In other words, a person who's had a CAR T and then relapse, individuals who've had a second CAR T and most of these have had same target, it's been BCMA-directed, actually did pretty well with that.
