Although administration of anti-CD19 chimeric antigen receptor (CAR)-T cell therapy takes place at authorized treatment centers, community oncologists still play an important role, particularly in the recognition of eligible patients and the management of adverse effects of the treatment.
A recent piece in The Oncologist detailed this crucial element of CAR-T administration and highlighted key aspects of CAR-T cell indications and eligibility for community oncology providers.1
To maximize the chances of a patient receiving CAR-T cell therapy, community oncologists should refer patients “early and broadly”, as the time of referral to CAR-T cell infusion can take 4 to 6 weeks.
Most broadly, patients with relapsed or refractory large B-cell lymphoma who have failed on 2 or more prior therapies can be referred. Patients who have failed or relapsed after first-line immunochemotherapy may also be eligible.
“Patients who progress on first-line therapy should be referred directly to academic centers whenever possible for management because high rates of relapse are observed with second-line treatments,” the authors wrote. “Academic centers are equipped to facilitate a smooth and rapid transition to the next line of therapy, especially CAR-T cell therapy, if patients are already receiving treatment there, which may be particularly important for patients with rapidly progressing disease.”
As part of this process, community oncologists should be aware of which centers in their state offer CAR-T cell therapy.
Community oncologists also play an important role in postinfusion care. Patients treated with CAR-T cell therapy are advised to carry a wallet card with them at all times that defines symptoms that could indicate a serious adverse event for which to seek medical attention. Any patient in response that does not experience a serious adverse event after a 4- to 8-week stay returns home.
These patients can experience prolonged hypogammaglobulinemia and B-cell aplasia, and some patients may require supportive care with IVIG. Prolonged cytopenias can also occur. Because the treatment causes immunosuppression, patients are at ongoing risk for serious infections after discharge as well.
“Coordination and communication between the local oncologist and CAR-T cell treatment oncologist are important during the months after patients return home from their minimum 4-week stay near the treatment center,” the authors wrote. “After this period, the authorized treatment center, in coordination with the local oncologist, may have patient follow-ups every 2 weeks until month 3, then decreasing in frequency to 6 months and 12 months after CAR T-cell infusion, then yearly until 5 years after CAR T-cell infusion,” the authors wrote.
- Jacobson CA, Farooq U, Ghobadi A. Axicabtagene ciloleucel, an anti-CD19 chimeric antigen receptor T-cell therapy for relapsed or refractory large B-cell lymphoma: practical implications for the community oncologist [published online October 4, 2019]. Oncologist. doi:10.1634/theoncologist.2019-0395