Characteristics and treatment patterns of relapsed/refractory diffuse large B-cell lymphoma in patients receiving ≥3 therapy lines in post-CAR-T era

Economic burden of generalized myasthenia gravis (MG) in the United States and the impact of common comorbidities and acute MG-events

BACKGROUND

This study assessed the incremental healthcare costs and resource utilization (HRU) associated with generalized myasthenia gravis (gMG), as well as variability in these outcomes among patients with gMG and common comorbidities and acute MG-related events.

METHODS

Adults with gMG and without MG were identified from a large US database (2017-2021). The index date was the first MG diagnosis (gMG cohort) or random date (non-MG cohort). Cohorts were propensity score matched 1:1. The gMG cohort included subgroups of patients with a 12-month pre-index (baseline) cardiometabolic or psychiatric comorbidity, or a post-index MG exacerbation/crisis. Monthly healthcare costs (2021 USD) and HRU were compared post-index between gMG and non-MG cohorts.

RESULTS

The gMG and matched non-MG cohorts each contained 2,739 patients. Mean incremental healthcare costs associated with MG were $4,155 (gMG: $5,567; non-MG: $1,411), with differences driven by incremental inpatient costs of $2,166 (gMG: $2,617; non-MG: $452); all p < 0.001. The gMG versus non-MG cohort had 4.36 times more inpatient admissions and 2.26 times more outpatient visits; all p < 0.001. Among patients with gMG in cardiometabolic (n = 1,859), psychiatric (n = 1,308), and exacerbation/crisis (n = 419) subgroups, mean monthly healthcare costs were $6,660, $7,443, and $17,330, respectively.

CONCLUSIONS

gMG is associated with substantial incremental costs and HRU, with inpatient costs driving the total incremental costs. Costs increased by 20% and 34% among patients with cardiometabolic and psychiatric conditions, respectively, and over three times among those with acute MG-related events. gMG is a complex disease requiring management of comorbidities and treatment options that can prevent acute symptomatic events.

Long-Term Host Immune Modulation Following Tisagenlecleucel Administration in Patients with Diffuse Large B-Cell Lymphoma and B-Lineage Acute Lymphoblastic Leukemia

Background: Chimeric antigen receptor (CAR)-T cells represent a potentially curative strategy for patients with relapsed or refractory (R/R) B-cell malignancies. To elucidate a possible host immune activation following CAR-T-cell infusion, we investigated the effects of tisagenlecleucel administration on the patients' immune populations in 25 patients with R/R diffuse large B-cell lymphoma (DLBCL) and B-lineage acute lymphoblastic leukemia (B-ALL). Methods: The modulation of CAR-T cells over time, the numeric changes, as well as the cytokine production capability of different lymphocyte populations and circulating cytokine levels, were analyzed. Results: Our results confirmed the ability of tisagenlecleucel to control the disease, with an overall response observed in 84.6% of DLBCL and in 91.7% of B-ALL patients at 1-month post-infusion, and showed that most patients who subsequently relapsed could undergo further treatment. Interestingly, we could document a significant increase in CD3⁺, CD4⁺, CD8⁺, and NK cells over time, as well as a decrease in Treg cells, and an increased IFNγ and TNFα production by T lymphocytes. Conclusions: Taken together, our results indicate that in patients with DLBCL and B-ALL, the administration of tisagenlecleucel is capable of inducing a marked and prolonged in vivo modulation/reshaping of the host immune system, both in children and adults.

Real-World Treatment Patterns After CD19-Directed CAR T Cell Therapy Among Patients with Diffuse Large B Cell Lymphoma

Introduction

CD19-directed chimeric antigen receptor T cells (CAR T) are approved for treatment of adults with relapsed/refractory diffuse large B cell lymphoma (DLBCL) following at least two lines of therapy.

Methods

This study describes real-world treatment patterns after CAR T in adults with DLBCL. It includes adults diagnosed with DLBCL in IBM MarketScan Commercial and Medicare Supplemental healthcare claims databases administered CAR T between 2017 and 2019 (index event) and at least 6 months of continuous health plan enrollment pre-index. Kaplan-Meier methods were used to estimate risk and time to first subsequent treatment after CAR T, as a proxy for CAR T failure.

Results

Among 129 patients meeting study criteria, most (123; 95.4%) were hospitalized during CAR T therapy. Median length of stay was 17 (25th–75th percentile, 13–22) days. Estimated 6-month risk of subsequent treatment was 36.2% (95% confidence interval [CI] 27.1–45.8%). During median follow-up of 195 (25th–75th percentile, 102–362) days, median time to the first line of therapy after CAR T, accounting for censoring, was 378 days (95% CI 226, not reached). Among 48 patients who received another therapy after CAR T, 58.3% received immunotherapy, 50.0% radiation therapy, 25.0% chemotherapy, 25.0% targeted therapy, and 12.5% hematopoietic stem cell transplant.

Conclusions

Among real-world patients with DLBCL treated with CAR T, the risk of not achieving a durable response is considerable; additional, effective options for DLBCL salvage treatment are needed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-022-02087-4.

Characteristics and Clinical Outcomes of Patients With Relapsed/Refractory Diffuse Large B-cell Lymphoma Who Received At Least 3 Lines of Therapies

INTRODUCTION

The treatment landscape for diffuse large B-cell lymphoma (DLBCL) has recently changed. We examined characteristics and clinical outcomes of DLBCL patients who initiated a third (3L) and fourth (4L) line of therapy during a contemporary time frame.

MATERIALS AND METHODS

Adult patients diagnosed with DLBCL who received ≥ 3L after January 1, 2014 were selected from the COTA database. Patients were grouped into cohorts by 3L or 4L initiation and further stratified by type of treatment received: chemotherapy or chemoimmunotherapy (CT/CIT), targeted therapy (TT), chimeric antigen receptor T cells (CAR-T), or salvage therapy consolidated with hematopoietic cell transplant (HCT). Patient characteristics, response rates, and overall survival (OS) were examined.

RESULTS

Among adult patients with relapsed/refractory (r/r) DLBCL, 212 (mean age; 61.8 years; 59.0% male) received their 3L and 127 (mean age: 61.0 years; 61.4% male) their 4L. Among those treated with their 3L and 4L, 55.2% and 50.4%, respectively, received CT/CIT; 26.9% and 34.6% received TT. The complete response rate of 3L patients was 9.4% for CT/CIT, 10.5% for TT, and 60% for CAR-T. Similar findings were seen with 4L patients (CT/CIT: 6.3%; TT: 15.9%; CAR-T: 53.8%). For those who received pharmacological treatment in 3L and 4L, median OS times were 7.7 and 4.4 months, respectively. Median OS times of patients who received cell-based therapies (CAR-T/HCT) were not reached.

CONCLUSION

In this study, a majority of r/r DLBCL patients were treated with CT/CIT or TT in 3L and 4L settings and had poor clinical outcomes, underscoring the need for more effective treatments.