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Transferring Bispecific Therapies to the Community
Bringing Bispecific Therapy Home: Best Practices for Transitioning Multiple Myeloma Patients from Academic to Community Care

Released: December 24, 2025

Caitlin Costello
Caitlin Costello, MD
Activity Information

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Key Takeaways
  • When considering bispecific antibody therapy for patients with relapsed/refractory multiple myeloma, early referral and coordinated planning between academic and community practices are essential for identifying candidates, securing access, and ensuring that infrastructure is in place for safe continuation of care.
  • Successful transition back to the community setting relies on clear communication, proactive infection prevention, and shared management strategies that support long-term, high-quality care for patients receiving bispecific antibodies.

Bispecific antibody (BsAb) therapy has quickly become an important option for patients with relapsed or refractory (R/R) multiple myeloma (MM). Four agents are now available in the United States that target CD3 on T-cells and either BCMA (teclistamab, elranatamab, linvoseltamab) or GPRC5D (talquetamab) on myeloma cells. All have been granted accelerated approval by the FDA for patients who have received ≥4 prior lines of therapy, including an immunomodulatory drug, a proteasome inhibitor (PI), and an anti-CD38 monoclonal antibody. In a population where historical median progression-free survival (PFS) after multiple relapses was measured in only a few months, these agents now routinely deliver responses lasting 1-2 years or more. The phase I/II trials for these agents—MajesTEC-1 (teclistamab), MagnetisMM-3 (elranatamab), MonumenTAL-1 (talquetamab), and LINKER-MM1 (linvoseltamab)—reported overall response rates (ORRs) of approximately 60% to 75%, with median PFS between 11.0 and 17.2 months. Initiating BsAb therapy introduces a set of clinical challenges that extend beyond the mechanics of writing a prescription, including determining the appropriate timing and clinical context for treatment, the logistics of administering BsAbs while balancing safe monitoring practices with ease of access, and long-term adverse event (AE) management.

AEs Associated With BsAb Therapy
As with any myeloma treatment, 1 important consideration for both patient selection and optimizing overall outcomes is understanding the AE profile of BsAbs. Cytokine release syndrome is a well-known class effect of all BsAb therapies and remains the most common early complication of this treatment in R/R MM. Immune effector cell–associated neurotoxicity syndrome (ICANS), is a less common but understandably worrisome class effect and requires careful neurologic monitoring during the first doses. Beyond these potential acute events, long-term AEs may include prolonged hypogammaglobulinemia and increased risk of infection in these heavily pretreated patients. The GPRC5D-directed BsAb talquetamab has fewer incidences of serious or high-grade infections vs the BCMA-targeted BsAb therapies, but it has other specific target-related AEs, such as dysgeusia, dry mouth, weight loss, skin changes, and nail fragility related to the expression of GPRC5D in keratinized tissues.

Early Communication Between Academic and Community Centers
For many people living with myeloma, this means navigating care between an academic referral center, where BsAb therapy is initiated due to the complexities of step-up dosing and monitoring to mitigate the effects of the acute AEs, and a community cancer practice, where the  ongoing doses can be administered once step-up dosing is complete. The successful navigation of the logistics and clinical nuances of that transition can make the difference between a life-extending therapy that feels sustainable and one that is technically available but practically out of reach. In cases where a patient’s community site cannot yet administer BsAb therapy, shared-care models can also be considered where an academic center administers the BsAb while the community team manages supportive measures like intravenous immunoglobulin (IVIG) and local lab monitoring.

An early critical step in this process is identifying patients who may be potential candidates for BsAb therapy before the point in care when they need immediate treatment. Often, this will be during second or third line of therapy, when it is clear that the patient’s disease may no longer be controlled by their current therapy and will soon experience disease relapse. Early referral for academic consultation provides time to review disease biology and pace of relapse, consider T-cell “fitness,” and avoid additional rounds of T-cell–depleting chemotherapy when possible. Also of importance, it allows for a realistic assessment of caregiver support, distance from the center, and the patient’s ability to manage the very real “full-time job” of being on an intensive therapy with frequent visits and monitoring.

In addition, prior authorization for BsAbs can be complex and time consuming, and travel to an academic center can strain a patient’s finances, employment, and family life before the first dose is given. When referral happens early, financial counselors, specialty pharmacies, and patient assistance programs have time to work with the patient to identify support options.

When an academic center is working with a community practice, it is important to consider which bispecific agents are available on the community practice’s formulary. It is crucial to select an agent that can be continued to be administered by the community practice, and teams should communicate effectively to select a BsAb therapy that aligns with formulary status, infusion capacity, and staff experience at both practices. When considering which BsAb therapy is most appropriate, it is also important to consider the patient’s comorbidities and priorities in regards to AE profiles. For some patients, the infection risk associated with BCMA targeting may be more concerning; for others, the idea of chronic taste disturbance, oral discomfort, or skin problems from a GPRC5D-directed agent may more difficult.

Managing Acute AEs During Step-Up Dosing and Transitioning to Long-Term AE Monitoring and Management for Ongoing Administration
Most often, academic centers perform the initial step-up dosing of BsAb therapy, where the risk of acute AEs is highest and teams are accustomed to managing CRS, neurotoxicity, and the rare but very serious immune effector cell–associated HLH-like syndrome. Inpatient admission remains common for patients with high disease burden, significant comorbidities, frailty, limited caregiver support, or long travel distances. However, outpatient step-up programs are becoming more common and, with the right infrastructure, patients can receive early doses without hospitalization. Some sites are exploring prophylactic tocilizumab before the first full dose in selected patients, based on emerging data that it can reduce the incidence of CRS without blunting efficacy, potentially making outpatient initiation safer and more feasible.

Once step-up dosing is completed successfully, the patient’s care and continued treatment can be transitioned back to their community care team. At this point, the focus shifts from acute AEs toward chronic AE risk mitigation. BCMA-directed bispecifics in particular can produce profound hypogammaglobulinemia on top of years of cumulative immune suppression from prior myeloma therapies, resulting in an increased risk of infection. A care plan can help to prevent repeated infections and may include monthly IVIG to mitigate hypogammaglobulinemia, antiviral prophylaxis, Pneumocystis jirovecii pneumonia prophylaxis, and thoughtful vaccination strategies, ideally implemented before BsAb therapy begins. Even with these prophylactic measures, a low threshold for infectious disease consultation and advanced diagnostics can be life-saving for patients whose immune systems are stretched to their limits and a care plan should be in place for both the short- and long-term treatment teams.

For patients continuing on a GPRC5D-directed BsAb therapy in the community, managing on-target AEs becomes a shared priority. Many patients experience early dysgeusia, dry mouth, and weight loss, sometimes severe enough to affect their nutritional status and quality of life. Palmar and plantar skin changes, rashes, and nail fragility are also common. Although topical and occasional systemic steroids, oral rinses, and meticulous skin and oral care can all help, one of the most powerful tools is dose and interval adjustment. Temporary treatment holds or individualizing the patient’s treatment schedule by spacing out doses may allow symptoms to improve without immediate loss of disease control.

Bridging Patient Care in Academic Medical Centers and Community Practice Centers
Successful transitions in patient care rarely hinge on a single protocol; they depend on good communication across both academic and community teams who see themselves as parts of 1 care unit rather than separate silos. As mentioned, communication should start long before a patient receives a BsAb therapy with discussions regarding optimal treatment selection. During the initial referral to an academic center, the community care team should provide a comprehensive clinical synopsis that includes the patient’s treatment history, baseline disease characteristics, prior AEs, and any relevant comorbidities that may influence eligibility or risk stratification for bispecific therapy. This information equips the academic team to make more tailored and efficient decisions and fosters a sense of shared accountability for patient outcomes.

After step-up dosing is complete and the patient is being transferred back to their community care team, clear written summaries should outline which bispecific was chosen and why, what step-up looked like, what degrees of CRS or ICANS occurred and how they were managed, what infectious complications have already been encountered, and what prophylactic and supportive measures are in place. Equally important is direct contact information so that a community oncologist can promptly consult with the initiating team in the event of unexpected neurologic symptoms, fever patterns, or dermatologic toxicities to avoid redundant workups or unnecessary travel and hospitalizations.

Incorporating the Newest Data With BsAbs
Because BsAb therapies have demonstrated safety and efficacy as single-agent treatment for R/R MM, they are now being explored in earlier settings and as part of novel combination regimens. For example, the confirmatory MajesTEC-3 phase III trial was presented at ASH 2025 and showed teclistamab plus daratumumab demonstrated substantial PFS benefit in R/R MM vs daratumumab plus pomalidomide plus dexamethasone or daratumumab plus bortezomib plus dexamethasone in patients with R/R MM after 1-3 prior lines of therapy, including a proteasome inhibitor and lenalidomide. Other ongoing phase III trials, such as MagnetisMM-5 and MagnetisMM-6 with elranatamab combinations, MonumenTAL-3 with talquetamab combinations, and the LINKER-MM5 trial with linvoseltamab combinations, will explore similar themes.

Another interesting approach is combining multiple BsAb modalities, such as a single-arm phase II trial exploring dual targeting with talquetamab plus teclistamab in patients with R/R MM with extramedullary disease. An updated analysis from ASH 2025 demonstrated deep, durable responses with this combination, with an ORR of 79% and a 12-month overall survival rate of 73%, and a safety profile as expected with the individual agents. Building on this, the phase III MajesTEC-7 trial is assessing teclistamab and talquetamab combinations in patients with newly diagnosed MM who are not candidates for ASCT (NCT05552222).

There are also several other BsAbs in clinical development that are building upon our current knowledge. Cevostamab is a BsAb that targets a different antigen, FcRH5, which is another target present on MM cells. Early data suggested that cevostamab can lead to high response rates, including a phase I study of cevostamab in patients with heavily pretreated R/R MM that showed an ORR of 43.1% in patients receiving the 160 mg target dose (NCT03275103). More recently, the phase Ib CAMMA 1 study of cevostamab in combination with pomalidomide and dexamethasone was associated with high response rates and durable remissions in patients with BCMA-naive R/R MM. In a small phase II study, cevostamab consolidation therapy is being explored following anti-BCMA CAR T-cell therapy in patients with predominantly heavily pretreated R/R MM, and results suggest nearly all patients remained in an MRD-negative complete response 1 year after CAR T-cell administration with this approach.

As BsAb therapy  moves from cutting-edge treatment to widely used options in late-line or potentially earlier-line settings, the question facing oncology practices is no longer if they will encounter the patients who should receive these agents, but more how prepared they will be when they do. Are potential candidates being identified early enough for thoughtful, proactive planning? Do local teams know which agents are accessible on their formulary and what infrastructure is required to administer them safely? Are pathways for managing CRS and ICANS, IVIG replacement, and infection workups already established before the first patient receives a BsAb? Addressing these practical questions is essential to transform BsAb therapy from a treatment modality provided only by large academic centers into a realistic, sustainable option for people living with myeloma in community settings.

Your Thoughts
What are your biggest challenges with managing patients with R/R MM being treated with BsAbs? Leave a comment to join the discussion!