Emerging evidence from Nature Medicine establishes that CAR T cell therapy can fundamentally alter the disease trajectory of smoldering myeloma, achieving sustained deep remissions. However, clinicians must recognize three critical implications: first, CAR T induces durable responses that prevent progression to symptomatic disease; second, severe toxicity affects approximately half of recipients, creating genuine treatment burden in an initially asymptomatic population; third, rigorous pre-treatment assessment and patient selection are now paramount. The traditional model of offering a therapy to all eligible candidates no longer applies. Instead, successful CAR T deployment requires comprehensive evaluation of individual risk factors, careful stratification, and honest discussion of toxicity risks with informed patients. This precision approach—rather than blanket application—will optimize outcomes while respecting the unique risk-benefit profile of treating precancerous disease.
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