Updated: September 2026
For patients with relapsed or refractory multiple myeloma, the next treatment may include CAR-T cell therapy or a bispecific antibody such as teclistamab, elranatamab or talquetamab.
These therapies can all produce meaningful responses, but the order in which they are used may matter. Receiving a bispecific antibody first does not automatically rule out CAR-T later. However, previous treatment against the same target may affect the response, and prolonged exposure to T-cell–redirecting therapy may influence the condition of the patient’s T cells.
For this reason, patients who may be eligible for CAR-T should consider requesting a specialist review before starting another T-cell–redirecting treatment.
CAR-T or a bispecific antibody: what is the main difference?
CAR-T is a personalized cell therapy. The patient’s T cells are collected, modified to recognize a target on the myeloma cells and then returned through a single infusion. The process requires cell collection, manufacturing, preparatory chemotherapy, hospitalization and close follow-up.
Bispecific antibodies are ready-made drugs that connect the patient’s existing T cells to myeloma cells. They can usually be started more quickly than CAR-T but are commonly given repeatedly over an extended period.
The practical differences include:
- Timing: A bispecific antibody may be available more quickly. CAR-T requires planning, T-cell collection and manufacturing.
- Treatment schedule: CAR-T is given as a single infusion, although the complete treatment process lasts several weeks. Bispecific antibodies normally require repeated doses.
- Treatment-free time: A successful CAR-T treatment may provide a period without continuous anti-myeloma therapy.
- Disease control: A patient with rapidly progressing disease may need treatment before CAR-T cells are ready.
- Immune effects: Both treatments activate T cells and can increase the risk of infections and other immune-related complications.
Neither option is automatically better for every patient.
Why can treatment order matter?
Several CAR-T therapies and bispecific antibodies target BCMA, a protein found on multiple myeloma cells.
Using one BCMA-directed treatment can affect the results of a later treatment aimed at the same target. Possible reasons include changes in BCMA expression on the myeloma cells and reduced T-cell fitness after prolonged exposure to T-cell–redirecting therapy.
Clinical evidence is still developing, but current data suggest that patients who receive a BCMA-directed bispecific antibody before BCMA CAR-T may, on average, have less favorable CAR-T outcomes than patients who have not previously received a BCMA-directed therapy.
This does not mean that CAR-T cannot work after teclistamab or another BCMA bispecific antibody. It means that the previous treatment, duration of exposure, response, timing and current disease status should be reviewed carefully.
When both options are available, some specialists may prefer to collect the patient’s T cells or proceed with CAR-T before extended treatment with a BCMA-directed bispecific antibody.
Can a patient receive CAR-T after teclistamab?
Yes, CAR-T may still be possible after teclistamab. Previous teclistamab treatment is not an automatic exclusion.
However, teclistamab and the currently established CAR-T therapies for multiple myeloma target BCMA. The medical team may therefore consider:
- How long the patient received teclistamab
- Whether the myeloma responded and how long the response lasted
- Why teclistamab was stopped
- Whether the disease still expresses BCMA
- The patient’s blood counts, infection history and immune status
- Whether adequate T cells can be collected
- How quickly the disease is progressing
- The time between the last teclistamab dose and T-cell collection
There is no single sequencing rule that applies to every patient. A specialist review is particularly important before assuming that CAR-T is no longer an option.
Can talquetamab be used before CAR-T?
Talquetamab is a bispecific antibody that targets GPRC5D rather than BCMA. Because it acts against a different target, it is being used and studied as a possible treatment before BCMA-directed CAR-T, including as bridging therapy for selected patients.
Bridging therapy is treatment used to control the myeloma while the patient is waiting for CAR-T manufacturing and infusion.
A multicenter study of patients with heavily pretreated multiple myeloma found that many patients receiving talquetamab as bridging therapy were able to proceed to BCMA CAR-T. The approach may be useful because it can reduce the disease burden without directly targeting BCMA.
However, talquetamab can cause significant side effects, including taste changes, reduced appetite, weight loss, infections and skin or nail problems. It is not suitable for every patient, and its timing in relation to T-cell collection requires specialist planning.
It should not be started as a bridge to CAR-T without coordination with the CAR-T team.
Can bispecific antibodies be used after CAR-T?
Bispecific antibodies may also be considered if multiple myeloma returns after CAR-T.
The choice may depend partly on the target:
- A BCMA-directed bispecific antibody, such as teclistamab or elranatamab, may remain active in some patients after BCMA CAR-T.
- A GPRC5D-directed treatment, such as talquetamab, attacks a different target and may be considered when the disease has already been exposed to BCMA-directed therapy.
- Other drug combinations, clinical trials, a second cellular therapy or treatments aimed at different targets may also be evaluated.
Doctors may request additional testing to understand why CAR-T stopped working and what options remain, including whether the original target is still present on the myeloma cells.
When might CAR-T be considered first?
CAR-T may be considered before a bispecific antibody when:
- The patient is medically fit for cell therapy
- The disease can remain controlled during the CAR-T preparation period
- T-cell collection and manufacturing can be arranged without excessive delay
- The patient wants the possibility of a treatment-free interval
- The patient lives far from a treatment center and repeated long-term dosing would be difficult
- The patient has not yet received a BCMA-directed bispecific antibody
- The treating team believes that delaying CAR-T could reduce future eligibility
Regulatory eligibility varies between countries and products. FDA approval criteria apply in the United States and do not automatically determine access in Israel or another country. Each treatment program evaluates patients according to its authorized protocol and clinical criteria.
When might a bispecific antibody be needed first?
A bispecific antibody may be considered first when:
- The myeloma is progressing too quickly to wait for CAR-T manufacturing
- CAR-T is not currently available
- T-cell collection cannot be performed
- The patient is not medically fit for the CAR-T process
- Immediate disease control is required
- Previous treatments or disease characteristics make another target preferable
- A bispecific antibody is being considered as carefully planned bridging therapy
A faster treatment is not necessarily the better long-term sequence. Whenever possible, the immediate need to control the disease should be considered together with the patient’s future CAR-T options.
Should T cells be collected before starting a bispecific antibody?
In some cases, early T-cell collection may preserve a future CAR-T option. This may be considered before prolonged exposure to a T-cell–redirecting bispecific antibody, particularly when the patient is already approaching CAR-T eligibility.
However, collecting cells early is not always possible or appropriate. The decision depends on treatment availability, disease stability, previous therapies, blood counts, current health and the protocol of the CAR-T center.
Patients should not delay necessary treatment while waiting for CAR-T without direct medical guidance.
Questions to ask before choosing the next treatment
- Is the patient currently eligible for CAR-T?
- Should T cells be collected before beginning another therapy?
- Does the proposed bispecific antibody target BCMA or GPRC5D?
- Could this treatment affect the effectiveness of a later CAR-T?
- How quickly does the disease need to be controlled?
- What treatment can be used while CAR-T cells are being prepared?
- What infections or immune complications has the patient already experienced?
- What options would remain if the proposed treatment stopped working?
- Does the treatment center accept international patients?
- How long would the patient and caregiver need to remain near the treatment center?
When should an international patient request a CAR-T review?
An international patient does not need to wait until every available treatment has failed before requesting an evaluation.
An earlier review may be useful when the patient:
- Has relapsed or refractory multiple myeloma
- Has already received two or more treatment lines
- Is considering teclistamab, elranatamab or talquetamab
- Has been told that CAR-T is unavailable or involves a long wait locally
- Needs an opinion about bridging treatment
- Has relapsed after a previous CAR-T or bispecific antibody
- Wants to understand whether treatment in another country is medically realistic
The review should include the complete treatment history, response to each therapy, recent blood tests, bone marrow and imaging results, current medications, infection history and a recent medical summary.
Request an individual multiple myeloma review
Israeli Hospitals coordinates medical-record reviews for international patients with relapsed or refractory multiple myeloma.
The reviewing team can assess whether CAR-T may still be possible, whether additional testing is required and how previous treatment with teclistamab, talquetamab or another bispecific antibody may affect the proposed treatment sequence.
Every case is assessed individually. Submission of medical records does not guarantee eligibility, acceptance, treatment availability or a particular outcome.
Contact us to request a medical review before deciding on the next treatment.
Sources
- Dhakal B, et al. Sequential targeting in multiple myeloma: talquetamab as a bridge to BCMA CAR-T . Blood. 2025.
- American Society of Clinical Oncology. Sequencing Bispecific Antibodies and CAR T-Cell Therapy in Multiple Myeloma . 2025.
- Liang X, et al. Comparison of CAR T-cell and bispecific antibody as third-line or later therapy for relapsed/refractory multiple myeloma . Journal for ImmunoTherapy of Cancer. 2024.
