Cost and Access, Future Directions, and Closing Pearls

Dr. Lunning acknowledges country-specific cost-access realities for novel therapies, noting he prescribes what the evidence supports and then navigates insurance processes including peer-to-peer reviews when needed. He highlights lenalidomide's oral formulation placing it under Medicare Part D, creating distinct financial considerations for Tafa-Len-R-CHOP. He acknowledges insufficient time to fully address cellular therapy access barriers, which represent their own 90-minute discussion.

Looking ahead, Dr. Graff is most excited about frontline bispecific antibody trial readouts, including EPCO-R-CHOP and GloFit-Pola-R-CHP combinations, along with the LOTIS-7 trial evaluating glofitamab combined with loncastuximab tesirine, and epcoritamab-lenalidomide chemo-free combinations. She anticipates that seeing bispecific antibodies in the frontline will raise the immediate question of what to do at relapse, predicting the answer will be anti-CD19 CAR-T.

Dr. Lunning anticipates frontline bispecific trials will be positive but raises concern about equitable global access, drawing parallels to the thalidomide-versus-lenalidomide divide in multiple myeloma where different regions adopted different standards, predicting a similar geographic divergence may emerge if both EPCO-R-CHOP and Pola-R-CHP prove positive as different parts of the world ride different frontline regimens.

Dr. Johnson highlights clinical trials dedicated to elderly patients exploring chemotherapy-free novel combinations, and emerging CAR-T versus CAR-T trials comparing CD19-targeted versus CD19/CD20 dual-targeted products as the next potential paradigm shift in second-line therapy.

Closing clinical pearls emphasize early referral and integrated community-academic care partnerships for CAR-T access, establishing institutional bispecific antibody management infrastructure now as these agents proliferate across tumor types, recognizing that transplant eligibility criteria do not define CAR-T eligibility, ensuring therapies given before apheresis are communicated to manufacturing teams, and maintaining the philosophy that every treatment decision has downstream consequences on subsequent options, making the right therapy at each line a patient-centric obligation.