During the Amercain Society of Hematology (ASH) meeting and exposition 2025, a major international congress in hematology, APLUSA presented a new real-world evidence poster on relapsed/refractory multiple myeloma. As BCMA-targeted options rapidly expand, clinicians face a practical challenge in daily care: how to sequence CAR-T cells and bispecific antibodies in the absence of head-to-head trials.

This multi-country analysis provides a clear snapshot of how these therapies are being selected and used across regions and treatment lines.

Why sequencing BCMA-targeted therapies matters

Multiple myeloma is the second most common hematologic malignancy. Despite improved outcomes with modern combinations,including proteasome inhibitors, IMiDs, corticosteroids, and anti-CD38 monoclonal antibodies, most patients ultimately relapse and may become triple-class refractory.

Targeting BCMA (B-cell maturation antigen) has opened a new era for these patients. Two key BCMA-directed approaches are now available in clinical practice:

• Anti-BCMA CAR-T cells (including ide-cel and cilta-cel)
• BCMA bispecific T-cell engagers / bispecific antibodies (including teclistamab and elranatamab)

While both target BCMA, they differ in mechanism of action, administration pathway, safety profile, and real-world feasibility. With limited direct comparative trials, real-world evidence is essential to understand how clinicians are sequencing them.

Study design: a multi-country, real-world chart review

APLUSA conducted a retrospective analysis of anonymous patient charts reported by onco-hematologists in EU5 (France, Germany, Italy, Spain, UK), United States, Japan and China.

The dataset included 911 unique patients treated outside clinical trials:

• 341 received anti-BCMA CAR-T cells
• 570 received a BCMA bispecific antibody

Data were collected across three periods (Oct–Dec 2022, Oct–Dec 2023, Jan–Mar 2025) to capture evolving practice patterns.

Key results from real-world practice

CAR-T and bispecifics are used in distinct patient profiles.

• Mean age was 62.8 years in the CAR-T group vs 68.9 years in the bispecific group.
• Across all treatment lines, bispecific recipients were consistently older and less fit.

CAR-T is more frequently used earlier in the pathway.

• 22% of CAR-T patients were treated in 2nd–3rd line, compared with 14% in the bispecific group.

Fitness (ECOG) and comorbidities shape treatment choice.

• In later lines (4th and 5th+), 82%/81% of CAR-T patients had ECOG 0–1, vs 71% of bispecific patients, suggesting CAR-T remains favored for fitter patients even late.
• Comorbidity burden was higher in the bispecific cohort (only 14% with none vs 23% in CAR-T).

What these findings mean for sequencing in relapsed/refractory multiple myelom

These real-world data show a consistent international pattern of treatment selection:

• CAR-T cells are preferentially used earlier and in younger, fitter patients.
• Bispecific antibodies are more often selected for older, less fit patients, and sometimes after CAR-T exposure in later lines.

In short, clinicians are already developing pragmatic sequencing strategies based on patient fitness, age, and pathway timing, helping bridge the gap left by limited comparative trial evidence.