Community-Based Care Delivery and Operational Considerations in R/R MM

Dr. Costa addresses community-based versus academic center care debates for complex patients requiring multiple therapy lines. While acknowledging academic center privileges in single-disease focus, he emphasizes that most Americans receive excellent cancer care closer to home in community practices. He advocates collaborative models where specialists provide consultative guidance through periodic consultations.

Dr. Costa strongly challenges perceptions that bispecific T-cell engagers require exclusive academic center administration. These therapies demonstrate outstanding efficacy and safety across diverse practice settings through robust phase 3 trials involving varying experience levels. Unlike CAR-T requiring specialized facilities, bispecific agents are off-the-shelf injectable subcutaneous drugs with manageable implementation requirements.

Essential community requirements include understanding treatment and toxicity profiles, developing mitigation plans, and recognizing cytokine release syndrome (CRS) with fever as primary manifestation. Effective CRS management involves proactive tocilizumab or dexamethasone use, with prophylactic approaches ensuring most patients experience only grade 1 CRS. MajesTEC-3 data supports this with only 1% intensive care unit admissions among 300 patients.

For community practices lacking integrated hospital systems, prophylactic strategies become particularly important. Dr. Costa recommends "pocket dexamethasone" protocols for patient self-administration, escalating to admission only for hypotension or hypoxia development. Required care typically involves supportive measures with severe complications remaining rare. He identifies perception rather than material barriers as primary obstacles, advocating bispecific accessibility for any physician treating multiple myeloma nationwide.