The treatment landscape for multiple myeloma (MM) continues to evolve rapidly, yet disparities in care and outcomes persist across several patient populations. Sagar Lonial, MD, FACP, FASCO, discusses data from the 2026 ASCO Annual Meeting highlighting ongoing challenges and opportunities in the care of special populations with MM.

Following these presentations, featured expert Sagar Lonial, MD, FACP, FASCO, was interviewed by Conference Reporter Medical Director Lauren Weinand, MD. Clinical perspectives from Dr Lonial on these findings are presented here.

Despite all the advances in MM that we have had in the last decade, several patient populations continue to experience unmet needs, including older adults, those who face barriers to accessing therapy, and high-risk patients. One of the real struggles that we have in caring for patients with MM in general is this dichotomy between transplant-eligible and -ineligible disease. In the United States, we do not typically view transplant eligibility as being purely an age-based decision, but that arbitrariness can create challenges when treating older patients.

At ASCO 2026, Jayasree Krishnan, MD, MSPH, presented real-world survival and toxicity data on the use of CAR T cells for relapsed/refractory MM in patients 75 years old and older (abstract 7541). What was important about this study was that the incidence of toxicities, particularly cytokine release syndrome and immune effector cell–associated neurotoxicity syndrome, and 1-year overall survival (OS) were not appreciably different between younger patients and patients aged 75 years and older. We have seen similar findings with transplant where toxicity, treatment-related mortality, and OS were comparable in carefully selected patients over and under age 75, taking into account the differences in age-adjusted survival. This tells me that some bias exists in terms of which patients are offered CAR T-cell therapy or transplant, particularly for individuals older than age 75. I think that we should give older patients the benefit of the doubt and consider referring them for these aggressive therapies.

The second category of patients who experience unmet needs that I want to touch on is those who face barriers to accessing therapy. We know that treatment access is a linchpin for achieving better outcomes, as patients who receive modern therapies are more likely to experience improved OS. Several studies have shown that treatment at a National Cancer Institute (NCI)–designated cancer center can improve OS by approximately 20%.

At ASCO 2026, Hamlet Gasoyan, PhD, reported that in the current era of triplet and quadruplet therapies, the OS outcomes of Black and White patients with newly diagnosed MM were equivalent when Black patients had equal access to therapy (abstract 11055). This is an important finding because, if we look at the Surveillance, Epidemiology, and End Results (SEER) database, these patients do not necessarily have equivalent OS outcomes. So, what are the differences between these patients that lead to different outcomes? The differences are related to patients’ access to care and the aggressiveness of the treatment they receive. This is an important observation that adds further fuel to the idea that equal access to appropriate therapy is needed for the best long-term outcomes.

Another study at ASCO 2026, which was presented by Emmanuel Ekpenyong, MD, evaluated access to bispecific T-cell engagers for relapsed/refractory MM and found that racial disparities existed in the use of this therapy (abstract 7545). This was a large retrospective cohort study that was conducted using the TriNetX data set (TriNetX, LLC). It is not 100% validated or easy to understand, but it clearly demonstrates that Black patients were not being offered bispecific T-cell engager therapy at the same frequency as White patients were, and this ultimately will impact their long-term outcomes. I think that this is just something we have to make sure we are paying attention to, particularly in an era in which we know that access to treatment can translate into significant improvements in remission, remission duration, and, ultimately, OS.

The last category from the special populations that I want to discuss is high-risk patients. I think it is important that we identify a high-risk patient and realize that they need to be treated differently, regardless of whether or not they are treated in the community or at an academic center. This does not just mean induction and access to consolidation, but really aggressive maintenance given for a long period. What frustrates me is when I see a patient with identified high-risk MM who received great induction and consolidation therapy and then was offered single-agent lenalidomide as maintenance therapy (which we know is really not enough for these patients), and then guess what? They relapse 1 or 2 years later, which, in the current era of MM treatment, really represents a lack of access to modern therapy because we know that these patients should be in remission for 3 to 5 years—if not longer—with more aggressive treatment.

So, I think that these represent some of the current unmet needs in the field of MM. Democratizing access to new treatments is incredibly important, and we need to partner with community sites to support referral pathways to centers that can offer these treatments and allow patients to have 24-hour access to care if they have cytokine release syndrome or immune effector cell–associated neurotoxicity syndrome.