Ryan Haumschild, PharmD, MS, MBA: In the back of our mind, we’re always thinking the payers need to cover this somehow. As we start combining more and more therapies, it still must make financial sense to the payer to get those great outcomes. The last question for you, Roy, rounding out this discussion, when you think about logistical access, getting people on-site for hospital-based infusion if it requires an infusion, or oral therapies and making sure that a patient has access, what are some of those pain points you have to consider when you’re trying to balance the IV [intravenous] vs oral? Or do you just give access across the board? I want to tease that out further because it’s higher cost, and it can have implications on the patient’s ability to receive therapy.

Roy Beveridge, MD: A larger portion of patients who are elderly with multiple comorbidities in fact end up in the community because they don’t meet qualifications for many trials. It’s difficult for a lot of folks to travel. I’ll say it again, from a payer’s perspective, I don’t think there’s a lot of push between one or the other. I know several years ago we all talked about how we’re all moving to orals. But that hasn’t happened. There are certain drugs that are never going to be given orally. Pills are great, but pills also are significantly complicated for certain patient populations because the adverse effects frequently with the orals are delayed. And people get confused when you look at the data in terms of when people want to take these drugs and how they perceive the adverse effects. IV is easy. Usually you get it, the nurse is sitting there talking to you. You’re going to have these problems in 3 or 5 days, whatever. Ryan, I’m not sure it makes a huge difference to the patient. To the payer, it may in terms of whether you hit Medicare Part B or whether you hit Part D and how the payment is constructed. But that’s the individual vis-a-vis plan and whether you’re talking about Medicare, Medicare Advantage, a DCE [Direct Contracting Entity], or whether we’re talking about commercial insurance.

Ryan Haumschild, PharmD, MS, MBA: Muhamed, did you want to say something from a clinician standpoint? I’m curious about your thoughts. Roy, you have some great things to weigh in on. But I’m curious from one of our frontline providers’ standpoint.

Muhamed Baljević, MD, FACP: Thank you. I wanted to echo a couple of important points that have been brought up by our colleagues and by Roy. It’s exactly right, myeloma is becoming one of the most expensive malignancies to manage. If you just take a quick trip down memory lane, the first documented case of myeloma in the literature was nearly 200 years ago. That poor woman was depicted completely bent with skeletal fractures, and was treated with root bark and quinine. And it’s written that she passed away in 5 days.

Fast-forwarding to now, we are in a position where we are thankfully transforming newly diagnosed myeloma into a chronic disease for a huge proportion of patients. The median survivals have expanded from single-digit years into now 10-plus years for certain subsets of patients. We’re looking at chronic management and chronic cost. That is a huge perspective I could only imagine from the payer’s side, but believe me, also from the patient’s side. And not just from a financial toxicity standpoint and from economic considerations, but also the adverse effect and the long-term risks, such as…malignancies. I don’t want to take too long, but I also want to mention that I absolutely agree, Josh laid it out beautifully. But in myeloma we do have a track record in terms of knowing that an additional drug may not necessarily keep pushing us forward too much. We do have approaches of total therapies, etc, and from my perspective I could imagine hopefully in our lifetimes potentially even…where we’re incorporating molecularly driven treatments with the important goal of delivering effective therapy in the front line and getting that long progression-free survival. And achieving even longer durations of treatment-free periods completely at the expense of being more treatment forward. We’re obviously going to need more data to justify that, but I could imagine that.

But we’re not at a point where we can endlessly continue adding all these agents together because patients with myeloma can’t handle that. Toxicity profiles as well are rapidly, even with the lower doses, hitting problematic stopping points. And lastly, clearly in the last 2-plus years, we live in the era of pandemic. Who knows how long it’s going to take us to get out of it in some safe way. Our patients are immunocompromised. Our approaches to disease management are long term. Our risks in terms of immunosuppression, hypogammaglobulinemia, infections, etc, are not trivial. Taking all this into consideration, even though it’s very exciting, no question, puts a lot of homework in front of us to try to figure out how to strike that balance between wanting to give the best outcomes to patients, but at the same time trying to understand that maybe not everybody needs 4 drugs. Maybe there could be patients who could do just as well with 3, and later on get incorporation with others. We still have a lot to learn.

This transcript has been edited for clarity.