What I really see is an evolution of how we approach patients at the time of diagnosis. We know that there has been a long history of innovations in myeloma. In my mind, there are three great epochs of how we approach the disease. The first one was the original days of myeloma therapy and antineoplastics with classical chemo, VAD, Alkeran (melphalan), Cytoxan (cyclophosphamide), bendamustine, things like that. Then, we move into the second-grade epoch of novel therapies. Immunomodulatory drugs like lenalidomide, proteasome inhibitors like bortezomib, and even monoclonal antibodies like daratumumab. Now, we're on the precipice of the third epoch, the T-cell redirection era, where we take bispecifics and CAR-Ts to really augment our own immune system. We know these drugs are extremely efficacious towards the end of the road, but there's active studies right now comparing it to frontline approaches. You get induction comparing between autologous transplant and CAR-T. Whereas I think we used to, and I know we used to, at newly diagnosed, say, "Okay, are you getting a transplant or not?" That is not going to be the future. The future is going to be bispecific or CAR-T, or bispecific and CAR-T, or is a T-cell engager part of your induction or part of your first line?
We're really trying to transform the way we approach this. In fact, we may be able to use T-cell redirection therapy to guide us towards cure. Using a variety of upfront genomic, immunologic, metabolomic, proteomic indices to predict optimal treatment approach, we may be able to get granular, instead of just saying, "VRd or Dara VRd followed by transplant, followed by maintenance is a great way to get long outcomes." We may be able to say, "No, you need to get daratumumab, teclistamab, and iberdomide as an induction. We consolidate you with a CAR-T. We give you two years of maintenance, and then you're cured." Where I see the future heading is personalized medicine at another level, a lot greater information about how to approach each individual patient and providing a high level of therapy, not just to people in the academic realm, but in the communities where we can still give drugs, like some of the greatest drugs that we have, plus the new range of bispecific antibodies and figuring out ways to optimally mitigate any cytokine release.
