Myeloma's Gray Zones: Sequencing, Oral Therapy, and Frailty

Choosing between B-cell maturation antigen (BCMA)–directed chimeric antigen receptor (CAR) T-cell therapy and bispecific antibodies, supporting patients on oral oncolytics, and using frailty assessments without delaying care are 3 gray zones where oncology nurses and advanced practice providers (APPs) have a role, according to Kate Kennedy, MSN, APRN, ACNP-BC, AOCNP.

Kennedy, outpatient malignant hematology APP team lead at Vanderbilt-Ingram Cancer Center in Nashville, Tennessee, served on a panel on sequencing bispecific antibodies and CAR T-cell therapy and comoderated a session on oral oncolytics and frailty at the 2026 National Summit on Hematologic Cancers. The meeting, held October 16-17, 2026, was themed "Defining the Standard Where the Guidelines End" and built around case-based sessions where evidence is limited.¹

Why is sequencing BCMA-directed therapy a gray zone?

Ciltacabtagene autoleucel (Carvykti) is approved after at least 1 prior line of therapy for lenalidomide-refractory multiple myeloma, based on the phase 3 CARTITUDE-4 trial (NCT04181827).² In March 2026, teclistamab (Tecvayli) plus daratumumab and hyaluronidase-fihj (Darzalex Faspro) was approved after at least 1 prior line, based on the phase 3 MajesTEC-3 trial (NCT05083169).^3,4

"We have now CAR T and bispecific antibodies both available in the second line for myeloma, but they're both BCMA targeting," Kennedy said. "So how do you choose that this person is going to get a BCMA-targeting CAR T versus a BCMA bispecific antibody?"

In her practice, Kennedy said, APPs may raise these questions, but "ultimately it's the physician who's making the final call." She compared the dynamic to a line from the film My Big Fat Greek Wedding: "We're the neck, but they're the head." That can mean asking, "Are you sure you want to use BCMA, a BCMA bispecific here when they haven't seen CAR T? 'Cause they might really be a good candidate for CAR T right now."

Patient priorities also shape the choice. CAR T-cell therapy is a more defined course of treatment, Kennedy explained, whereas with bispecific antibodies, "we have no data to stop it," she said. Her team has published work on extending dosing intervals. "So what kind of things matters to the patient? Like, are they somebody who's comfortable coming off of treatment?"

What should nurses know about oral oncolytics?

Kennedy co-moderated the oral oncolytics session with Lindsay Adkins, MSN, FNP-BC, BMTCN, of the Sarah Cannon Transplant and Cellular Therapy Program. "Just because it's oral, it doesn't mean it's easy," Kennedy said. "Like just because it's oral doesn't mean it doesn't have side effects. And just because it's oral doesn't mean that the patients are taking it."

One case involved a young patient whose insurance technically covered her drug, but at nearly $8,000 a month, after a manufacturer assistance program closed to insured patients, Kennedy said.

On adherence, Kennedy said wording matters. "Hey, you're taking your meds, right? You're gonna get a very different answer than if we say, tell me how you're taking your meds every day, or how many missed doses have you had in the last month, just assuming that there are going to be missed doses."

A panelist from the University of North Carolina described a pharmacist-driven program that flags patients using an outside specialty pharmacy as higher risk for added support. Prior coverage has also stressed the nursing role in clarifying regimens and missed-dose plans.⁵

How can frailty assessments help or delay care?

Frailty assessments can help optimize patients before transplant or identify those for whom transplant may not be appropriate, Kennedy said, but they may also delay definitive care to the point that clinicians "miss our window of opportunity." She added, "I don't think we have an answer. So that's a big gray zone."

What are the key takeaways for oncology nurses?

• Track prior BCMA-directed therapy and raise CAR T-cell therapy when it has not been considered.
• Ask patients whether they prefer fixed-duration treatment or the security of ongoing therapy.
• Screen patients on oral therapy for cost, access, and adverse effects.
• Ask open-ended adherence questions that assume some missed doses.
• Use frailty assessments to optimize patients without losing the window for definitive care.

References

1. Binaytara's 2026 National Summit on Hematologic Cancers reinvents the medical conference—and invests $250,000 in research. Binaytara. May 18, 2026. Accessed October 28, 2026. https://binaytara.org/news/news/binaytara-s-2026-national-summit-on-hematologic-cancers-reinvents-the-medical-conference-and-invests-250-000-in-research
2. San-Miguel J, Dhakal B, Yong K, et al. Cilta-cel or standard care in lenalidomide-refractory multiple myeloma. N Engl J Med. 2023;389(4):335-347. doi:10.1056/NEJMoa2303379
3. FDA approves teclistamab in combination with daratumumab hyaluronidase-fihj for relapsed or refractory multiple myeloma. FDA. March 5, 2026. Accessed October 28, 2026. https://www.fda.gov/drugs/resources-information-approved-drugs/fda-approves-teclistamab-combination-daratumumab-hyaluronidase-fihj-relapsed-or-refractory-multiple
4. Hoyt B. FDA approves teclistamab combination for R/R multiple myeloma in latest CNPV review. Oncology Nursing News. March 5, 2026. Accessed October 28, 2026. https://www.oncnursingnews.com/view/fda-approves-teclistamab-combination-for-r-r-multiple-myeloma-in-latest-cnpv-review
5. Rikal M. Simplifying oral oncolytic adherence in oncology practice. Oncology Nursing News. August 23, 2025. Accessed October 28, 2026. https://www.oncnursingnews.com/view/simplifying-oral-oncolytic-adherence-in-oncology-practice