4 lessons from real world use of CAR-T cell therapy
A review of CAR-T cell therapies in relapsed/refractory aggressive B-cell lymphoma has concluded that efficacy and safety in real-world experience supports the findings of pivotal trials.
Axicabtagene ciloleucel (axi-cel) has a higher degree of toxicity and requires inpatient administration, but also appears to have the quickest manufacturing turnaround time (<3 weeks), according to a paper in the American Journal of Haematology.
Tisagenlecleucel (tisa-cel) tends to be favoured in older adults due to the lesser toxicity and may be administered in the outpatient setting but has a turnaround time of about 1 month.
The review also noted that the use of bridging therapy prior to axi-cel infusion seems to be associated with decreased efficacy, although this may be a result of higher risk patients being treated in the real world.
The authors noted that the cost per quality-adjusted life year of axi-cel and tisa-cel for large B-cell lymphoma therapy in the US is below the willingness-to-pay threshold in cancer treatment. Cost-effectiveness studies for lisocabtagene maraleucel (liso-cel) and CAR-T cell therapy in other countries are not yet available.
“A substantial amount of the costs incurred from CAR-T cell therapy is attributed to hospitalisation and office visits. Improving therapies in the outpatient setting may reduce costs and therefore allow additional patients to be treated.”
COVID-19 problematic in post-ASCT patient
Melbourne clinicians have reported a novel case of asymptomatic COVID-19 infection in the early period following autologous stem cell transplant (ASCT) for stage IIIB refractory Hodgkin lymphoma in the context of well controlled HIV infection.
The COVID-19 infection appeared to have resulted in poor graft function and prolonged pancytopenia.
“On day +52 post-transplant, when attending for transfusion support, the patient reported a painful palate, attributed to burning his mouth with food. Testing for SARS-CoV-2 by PCR was performed and returned positive.”
Retrospective testing found the 51-year-old male had been COVID-19 positive as early as day +5 and he remained so until day +95.
“The impaired T-lymphocyte responses related to his recent ASCT and long-standing HIV may have contributed to a lack of a SARS-CoV-2 inflammatory response in our patient, as being implicated in the severity of COVID-19 in solid-organ transplant recipients.”
“It would appear plausible that SARS-CoV-2 could be implicated in poor graft function following ASCT, even without symptoms. This has potential implications for investigation of prolonged cytopenias in immunocompromised patients during the current COVID-19 pandemic.”
Top 10 Choosing Wisely recs for COVID-19
An international taskforce on Choosing Wisely for COVID-19 has released its top ten recommendation for the general public and for physicians.
The 18-member taskforce from India, Canada, the US and UK, encompassed the disciplines of public health, primary care, infectious diseases, respiratory medicine, critical care and more.
The five recommendations for the general public reinforce prevention messages, when to get tested and when to seek medical help.
The five recommendations for physicians focus on the management of COVID-19. They are:
- Do not use prescribe unproven or ineffective therapies for COVID-19
- Do not use drugs like remdesivir and tocilizumab except in specific circumstance where they may be of use
- Do use steroids prudently only in patients with hypoxia, and monitor blood sugar levels to keep them in normal range
- Do not routinely perform investigations that do not guide treatment, such as CT scans and inflammatory markers
- Do not ignore the management of critical non-COVID-19 disease during the pandemic.
Read more in Nature Medicine