Comparative effectiveness of CAR-T cell therapy vs. teclistamab in relapsed/refractory multiple myeloma: A real-world propensity-matched analysis revealing survival advantages and treatment disparities Free

Background:

CAR-T cell therapy and bispecific antibodies (BsAbs) such as Teclistamab have expanded therapeutic options for relapsed/refractory multiple myeloma (RRMM). While both have shown efficacy in clinical trials, real-world data comparing survival outcomes and assessing treatment disparities across demographic and socioeconomic groups remain limited.

Methods:

Using the TriNetX US Collaborative Network of 65 healthcare organizations, we identified adult RRMM patients treated with CAR-T therapy (n = 1,109) or Teclistamab (n = 951). A 1:1 propensity score matching approach was applied to balance cohorts on demographics and comorbidities, resulting in 695 matched patients per group. The primary outcome was 5-year all-cause mortality. Secondary analyses included hazard ratios, odds ratios, Kaplan-Meier survival estimates, and evaluation of pre-matching disparities.

After matching, CAR-T therapy was associated with a significantly lower 5-year mortality rate compared to Teclistamab (16.8% vs. 23.3%; risk difference: −6.5%, 95% CI: −10.7 to −2.3; p = 0.003). The hazard ratio for mortality was 0.50 (95% CI: 0.39–0.64), indicating a 50% reduction in risk with CAR-T. Kaplan-Meier analysis confirmed this survival advantage (log-rank p < 0.001), with consistent separation of survival curves over time. Despite a slightly higher survival probability at the end of follow-up in the Teclistamab group (58.9% vs. 56.7%), the overall survival trajectory favored CAR-T (Table 1). Before matching, notable disparities in treatment allocation were observed. White patients were more likely to receive CAR-T (73.7% vs. 62.8%; p < 0.001), while Black patients (21.1% vs. 16.5%; p = 0.007), older adults, and those with socioeconomic risk factors (Z55–Z65) were more often treated with Teclistamab (Table 2).

Discussion:

This real-world analysis demonstrates that CAR-T therapy offers a substantial survival benefit over Teclistamab in matched RRMM patients. The Kaplan-Meier analysis, risk metrics, and hazard ratio reinforce this advantage. However, disparities in access to CAR-T were evident, with Black, older, and socially vulnerable patients being less likely to receive it. These inequities persist despite the superior outcomes associated with CAR-T, raising concerns about systemic barriers in access to advanced therapies. We must recognize the need for equitable access and work towards achieving it.

Conclusion:

CAR-T therapy significantly outperforms Teclistamab in reducing 5-year mortality in RRMM patients, even after balancing for key clinical and demographic variables. Yet, its use remains inequitably distributed across racial and socioeconomic lines. These findings call for immediate and concerted efforts to ensure equitable access to high-efficacy therapies through structural reform, inclusive referral practices, and payer policy innovation. The urgency of this task cannot be overstated, and we must all be committed to making these changes.

Table 1. Clinical Outcomes After Matching in RRMM Patients (n = 695 per Group) Table 2. Disparities in Treatment Allocation Before Matching

¹ Age data as per full dataset summary