IMS 2026 | ASCO Living Guideline updates in multiple myeloma: CAR T-cell therapy versus bispecific antibodies

So I’m first author, co-first, I should say, on the 2026 Living Guidelines for Myeloma from ASCO, the American Society of Clinical Oncology. It has been a team effort. I’m rotating, so I’ll be rotating off as a temporary co-chair in due time. Honestly, I think the biggest shift in the field right now, and you can see all of us, including within the International Myeloma Working Group, are struggling with this, is up until December of 2025, all of us would say that CAR-T should be preferred before bispecifics in patients with access to both modalities, unless there’s some reason they cannot get CAR-T therapy because of logistical considerations or because of clinical considerations that they can’t get to a CAR-T center or disease too explosive. MajesTEC-3 has completely turned that on its head. And even our IMWG guidelines on this exact topic that were written barely two years ago are probably out of date with that in mind. So we wrestle with this as a field because our first iteration of the guidelines for myeloma by ASCO published in the distant world of 2025, said that CAR-T therapy should be preferred before bispecifics and early relapse because, number one, bispecifics were only approved in later lines at that point in time, and number two, the CAR-T data looked terrific. The challenge is twofold. Number one, teclistamab, so teclistamab and daratumumab is now approved in one prior line in both the U.S. and Europe based on MajesTEC-3. And those data look sensational. And number two, that regimen is actually much more tolerable than the tech of yore because we’re using IVIG more. We’re de-escalating with the teclistamab. So it’s not once a week for forever. It goes to once a month. And number two, it seems to be doing really well, maybe because these patients are earlier lines, less exhausted T cells, less aggressive disease biology. The daratumumab honestly may be adding some secret sauce to the regimen we don’t entirely understand in terms of preventing resistant clones from emerging. These patients are doing terrifically. So the biggest change that we made in our guidelines is that CAR-T therapy and Tec-Dara are now on equal footing in terms of what you recommend for patients at first relapse. That is wild. But honestly, we actually didn’t debate that much on it as a group. Compared to some of the other stuff in debate, it was blood, sweat, and tears going into it, trying to debate on what to say. Here, we all agree. I think patients should be aware of their options. So I would still strongly recommend for community oncologists, right, that you at least let your patient hear about CAR-T therapy from the big city, from wherever the nearest authorized treatment center is. However, two years ago, I made a kind of, made a funny face if my patient could have gotten CAR-T chose bispecific antibodies. Now, no more funny faces. If a patient is aware of their options and chooses the off-the-shelf option available closer to home with bispecifics, Great. Don’t worry about the sequencing is what I would say. If teclistamab PFS at three years is 87%, those patients will do so well that even if they have a relapse lay out there, we’re going to have even better options then. So I wouldn’t stress about losing your candidacy for CAR T therapy because again, 2029, 2030 is going to look so different for CAR T therapy that I’m not concerned. Whatever you choose, Bispecifics or Teclistamab, go with it, live your life, and be happy with it.

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