Blood cancers

Preparing patients with DLBCL for CAR T-cell therapy


Chimeric antigen receptor (CAR) T-cell therapy may be a novel treatment but it is a therapy that is very deliverable, says Dr Michael Dickinson, Clinical Haematologist at the Peter MacCallum Cancer Centre in Melbourne. In a follow-up to the CAR-T Connect medical education event hosted by Novartis in August, the limbic spoke with Dr Dickinson about how CAR-T cell therapy is not only pushing the boundaries of cancer treatment, but is changing the way healthcare systems are interacting in Australia.

A patient’s journey with CAR T-cell therapy starts with an email or phone call

“The process with a patient can start with just an email or phone call as well. We can be referred patients from across the State or country and will discuss the eligibility for treatment. If all looks well we’ll do the apheresis and send off the cells for manufacturing. That can take several weeks to complete,” he noted. Depending on the patient’s disease, there will be a plan for patient management while waiting for the cells to be manufactured. “For some patients we do not need to do anything,” explained Dr Dickinson. “While others might need further bridging therapy to see them through, either by us or their referring physician. When we have the delivery date for the cells, we re-evaluate the patient here at Peter Mac, re-checking the lymphocytes a few days prior to infusing the CAR T-cells.”

Dr Dickinson explained how centres across Australia connect each week to discuss patient cases and benefit from a collective ‘brains trust’ and shared experience. “For a while now, every Tuesday doctors, nurses and associated stakeholders meet to discuss the delivery of chimeric antigen receptor (CAR) T-cell therapy in Australia. While it’s not unique to medicine (they have been doing this in paediatrics for some time), I believe it’s something new for adult medicine – and it’s connecting health care systems in a way that has not been done before.”

Post infusion, centres keep a close eye on patients

“Then after infusion we’re monitoring them [patients] closely for cytokine release syndrome and neurotoxicity.1,2 Around half of the patients may need to be admitted for observation (usually for fever during the first week), the remainder are treated in an outpatient setting. We require patients to stay close to the CAR-T hospital for the four weeks after infusion though so we can respond to adverse events quickly if neede.d. During that time, patients are usually  seen by our CAR-T nurse consultant Nicole O’Leary or our CAR-T fellow. Patients  come to an outpatient clinic every other day. Usually by two weeks post infusion the likelihood of an emergent adverse event declines3 and by four weeks they can usually repatriate home,” explained Dr Dickinson.

Two weeks, one month, 3 months and 12 months are the follow-up milestones

“As I mentioned, the likelihood of an emergent adverse event seems to decline after two weeks. So that’s when we can all breathe a little easier with regards to tolerability. For efficacy, at Peter Mac we do an exploratory positron emission tomography (PET) scan at one month, three months and 12 months to confirm the depth of response,” noted Dr Dickinson. “In between, we’re seeing patients every couple of months at the clinic or via Telehealth for those out of the metro area and we work  closely with referring haematologists to manage any issues that might arise.

Keep CAR T-cell therapy in mind as you make treatment decisions

Dr Dickinson emphasised the increasing importance CAR T-cell therapy could play in treatment choices. “Even now, in considering our choices of treatment for patients with lymphoma,  we should consider the effect of those therapies on future lymphocyte harvesting. If we want to keep CAR T-cell therapy in play for more patients with relapsed DLBCL, we need to consider this treatment and refer them as early as possible to ensure their disease can withstand the manufacturing timeframe and that they are well enough to collect lymphocytes in a timely manner.”

 

This article was developed by the limbic at the request of and with funding from Novartis.

References:

  1. Wudhikam K, et al. Blood Adv 2020;4(13):3024-3033.
  2. Kymriah (tisagenlecleucel) Approved Product Information.
  3. Chavez JC, et al. Ther Adv Hematol 2019;10:2040620719841581.

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