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Goto H, Onozawa M, Teshima T. Novel CAR T cell therapies for patients with large B cell lymphoma. Int J Hematol 2024; 120:6-14. [PMID: 38795249 DOI: 10.1007/s12185-024-03792-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 05/07/2024] [Accepted: 05/14/2024] [Indexed: 05/27/2024]
Abstract
Approximately 60-70% of patients with large B cell lymphoma (LBCL) achieve long-term remission or a cure after initial treatment. However, patients who relapse or are refractory to initial treatment have a poor prognosis. Chimeric antigen receptor (CAR) T cell therapy has recently attracted attention for its potential to provide a cure or long-term remission even for LBCL that has relapsed or is refractory to conventional chemotherapy. Currently, three CAR T cell products are clinically available for LBCL: tisagenlecleucel (tisa-cel), axicabtagene ciloleucel (axi-cel) and lisocabtagene maraleucel (liso-cel). These CAR T cell products were initially approved as third- or later-line therapies worldwide. Recently, axi-cel and liso-cel have become feasible as second-line therapies for patients with early relapsed or refractory disease after first-line chemotherapy. Although a large body of data on CAR T cell therapy has been accumulated, the clinical question of how to choose between these three available CAR T cell products has yet to be resolved. The appropriate approach to treatment selection for patients who relapse after CAR T cell therapy also remains unclear. This review discusses treatment strategies to maximize the benefits of CAR T cell therapy.
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Affiliation(s)
- Hideki Goto
- Division of Laboratory and Transfusion Medicine, Hokkaido University Hospital, W7, N15, Kita-Ku, Sapporo, Hokkaido, Japan.
| | - Masahiro Onozawa
- Department of Hematology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Takanori Teshima
- Division of Laboratory and Transfusion Medicine, Hokkaido University Hospital, W7, N15, Kita-Ku, Sapporo, Hokkaido, Japan
- Department of Hematology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
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Oluwole OO, Neelapu SS, Ray MD, Limbrick-Oldfield EH, Wade SW, Kanters S, Patel AR, Locke FL. Network meta-analysis of CAR T-Cell therapy for the treatment of 3L+ R/R LBCL after using published comparative studies. Expert Rev Anticancer Ther 2024; 24:457-465. [PMID: 38646700 DOI: 10.1080/14737140.2024.2343801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 03/25/2024] [Indexed: 04/23/2024]
Abstract
INTRODUCTION Studies have compared chimeric antigen receptor (CAR) T-cell therapies and salvage chemotherapy in relapsed/refractory large B-cell lymphoma (LBCL) patients, but further evidence of their relative effectiveness is warranted. METHODS Our systematic review identified studies comparing efficacy and safety outcomes of axicabtagene ciloleucel (axi-cel), lisocabtagene maraleucel (liso-cel) and tisagenlecleucel (tisa-cel) trials to salvage chemotherapy cohorts in LBCL patients with ≥2 prior lines of treatment; and an extended evidence network included indirect comparisons comparing CAR T-cell therapies. We conducted network meta-analyzes using Bayesian hierarchical modeling. RESULTS Three studies comparing ZUMA-1 (axi-cel), TRANSCEND (liso-cel) and JULIET (tisa-cel) trials to salvage chemotherapy within the SCHOLAR-1 cohort were identified. Axi-cel (odds ratio [OR]:5.63; 95% credible interval [CrI]:2.66-12.42) and liso-cel (OR:4.26; 95%CrI:2.33-7.93) showed a significant increased overall response rate compared to tisa-cel, but not to one-another. Axi-cel demonstrated significant improvements in overall survival relative to liso-cel (hazard ratio [HR]:0.54; 95%CrI:0.37-0.79) and tisa-cel (HR:0.47; 95%CrI:0.26-0.88). Higher rates of grade ≥3 neurological events were observed with axi-cel than with tisa-cel and liso-cel. CONCLUSIONS We highlight important differences in clinical outcomes between CAR T-cell therapies. Axi-cel demonstrated improved overall survival compared to tisa-cel and liso-cel, and both axi-cel and liso-cel showed higher response rates compared to tisa-cel.
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MESH Headings
- Humans
- Bayes Theorem
- Biological Products
- Immunotherapy, Adoptive/methods
- Immunotherapy, Adoptive/adverse effects
- Lymphoma, Large B-Cell, Diffuse/therapy
- Lymphoma, Large B-Cell, Diffuse/pathology
- Lymphoma, Large B-Cell, Diffuse/immunology
- Network Meta-Analysis
- Receptors, Antigen, T-Cell
- Receptors, Chimeric Antigen/immunology
- Salvage Therapy/methods
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Affiliation(s)
- Olalekan O Oluwole
- Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sattva S Neelapu
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Sally W Wade
- Wade Outcomes Research & Consulting, Salt Lake City, UT, USA
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Strati P, Gregory T, Majhail NS, Jain N. Chimeric Antigen Receptor T-Cell Therapy for Hematologic Malignancies: A Practical Review. JCO Oncol Pract 2023; 19:706-713. [PMID: 37406255 DOI: 10.1200/op.22.00819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 03/09/2023] [Accepted: 05/24/2023] [Indexed: 07/07/2023] Open
Abstract
Chimeric antigen receptor T-cell (CAR-T) therapy has become an established therapeutic approach for the treatment of hematologic malignancies. The field continues to evolve rapidly and newer-generation constructs are being designed to enhance proliferative capacity, and achieve long-term persistence and greater efficacy with an overall lower incidence of toxicity. Initial clinical application of CAR-T therapies has focused on relapsed and/or refractory hematologic malignancies, and Food and Drug Administration-approved CAR-T products targeting CD19 are available for B-cell acute lymphoblastic leukemia and low- and high-grade B-cell non-Hodgkin lymphoma, and targeting B-cell maturation antigen are available for multiple myeloma. Cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome have been recognized as class specific toxicities associated with these novel therapies. In this review, we focus on the clinical application of CAR-T therapies in adult patients with hematologic malignancies, including access issues, outpatient administration, and appropriate timing for referring a patient to a CAR-T treatment center.
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Affiliation(s)
- Paolo Strati
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tara Gregory
- Colorado Blood Cancer Institute, Denver, CO
- Sarah Cannon Transplant and Cellular Therapy Program at Presbyterian/St Luke's Medical Center, Denver, CO
| | - Navneet S Majhail
- Sarah Cannon, Nashville, TN
- Sarah Cannon Transplant and Cellular Therapy Program at TriStar Centennial, Nashville, TN
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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Visweshwar N, Rico JF, Killeen R, Manoharan A. Harnessing the Immune System: An Effective Way to Manage Diffuse Large B-Cell Lymphoma. J Hematol 2023; 12:145-160. [PMID: 37692863 PMCID: PMC10482611 DOI: 10.14740/jh1112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/01/2023] [Indexed: 09/12/2023] Open
Abstract
Diffuse large B-cell lymphoma (DLBCL) is a heterogenous hematological disorder with malignant potential controlled by immunological characteristics of the tumor microenvironment. Rapid breakthrough in the molecular pathways has made immunological approaches the main anchor in the management of DLBCL, with or without chemotherapeutic agents. Rituximab was the first monoclonal antibody approved for the treatment of DLBCL. Following rituximab that transformed the therapeutic landscape, other novel immunological agents including chimeric antigen T-cell therapy have reshaped the management of relapsed/refractory DLBCL. However, resistance and refractory state remain a challenge in the management of DLBCL. For this literature review, we screened articles from Medline, Embase, Cochrane databases and the European/North American guidelines from March 2010 through October 2022 for DLBCL. Here we discuss immunological agents that will significantly affect future treatment of this aggressive type of lymphoma.
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Affiliation(s)
- Nathan Visweshwar
- Department of Hematology, University of South Florida, Tampa, FL, USA
| | - Juan Felipe Rico
- Department of Pediatrics, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Robert Killeen
- Department of Hematology, Moffitt Cancer Center, Tampa, FL, USA
| | - Arumugam Manoharan
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
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Mucha SR, Rajendram P. Management and Prevention of Cellular-Therapy-Related Toxicity: Early and Late Complications. Curr Oncol 2023; 30:5003-5023. [PMID: 37232836 DOI: 10.3390/curroncol30050378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 04/28/2023] [Accepted: 05/02/2023] [Indexed: 05/27/2023] Open
Abstract
Chimeric Antigen Receptor T (CAR-T) cell therapy has dramatically changed prognosis and treatment of relapsed and refractory hematologic malignancies. Currently the 6 FDA approved products target various surface antigens. While CAR-T therapy achieves good response, life-threatening toxicities have been reported. Mechanistically, can be divided into two categories: (1) toxicities related to T-cell activation and release of high levels of cytokines: or (2) toxicities resulting from interaction between CAR and CAR targeted antigen expressed on non-malignant cells (i.e., on-target, off-tumor effects). Variations in conditioning therapies, co-stimulatory domains, CAR T-cell dose and anti-cytokine administration, pose a challenge in distinguishing cytokine mediated related toxicities from on-target, off-tumor toxicities. Timing, frequency, severity, as well as optimal management of CAR T-cell-related toxicities vary significantly between products and are likely to change as newer therapies become available. Currently the FDA approved CARs are targeted towards the B-cell malignancies however the future holds promise of expanding the target to solid tumor malignancies. Further highlighting the importance of early recognition and intervention for early and late onset CAR-T related toxicity. This contemporary review aims to describe presentation, grading and management of commonly encountered toxicities, short- and long-term complications, discuss preventive strategies and resource utilization.
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Affiliation(s)
- Simon R Mucha
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Prabalini Rajendram
- Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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Mohty R, Moreno Vanegas Y, Chavez JC, Kharfan-Dabaja MA. Lisocabtagene maraleucel for relapsed or refractory large B-cell non-Hodgkin lymphoma. Expert Rev Anticancer Ther 2023; 23:121-126. [PMID: 36662602 DOI: 10.1080/14737140.2023.2171397] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Chimeric antigen receptor T (CAR T) cell therapy epitomizes the success of T cell engineering. Today, it is an integral component of the treatment algorithm for various types of B-cell non-Hodgkin lymphoma (NHL). Large B-cell lymphoma (LBCL) is the most common subtype of NHL accounting for 30-35% of cases. A lack of response to second-line therapy portends a poor prognosis as only 7-15% of patients attain complete remission (CR) with subsequent conventional chemoimmunotherapy. AREAS COVERED Lisocabtagene maraleucel (liso-cel) is an autologous CD-19 directed CAR T-cell product with a 4-1BB co-stimulatory domain administered as a sequential infusion of 2 separately manufactured components: CD8+ and CD4+ CAR T-cells in equal doses. Liso-cel showed an impressive objective response rate of 73% (CR = 53%) in patients who had received a median of 3 prior therapies. Median time-to-first CR or partial response (PR) was 1 month. EXPERT OPINION When evaluated in the second line setting in LBCL, liso-cel demonstrated superior event-free survival (EFS) versus standard of care. While acknowledging that choice of a particular CAR T-cell is based chiefly on familiarity of the treating physician with a specific product, liso-cel definitely represents an important addition to the treatment armamentarium of R/R LBCL whether in the second-line setting or beyond.
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Affiliation(s)
- Razan Mohty
- Division of Hematology-Oncology and Blood and Marrow Transplantation and Cellular Therapy Program, Mayo Clinic, Jacksonville, FL, USA.,Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Yenny Moreno Vanegas
- Division of Hematology-Oncology and Blood and Marrow Transplantation and Cellular Therapy Program, Mayo Clinic, Jacksonville, FL, USA
| | - Julio C Chavez
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology and Blood and Marrow Transplantation and Cellular Therapy Program, Mayo Clinic, Jacksonville, FL, USA
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Sheikh S, Migliorini D, Lang N. CAR T-Based Therapies in Lymphoma: A Review of Current Practice and Perspectives. Biomedicines 2022; 10:1960. [PMID: 36009506 PMCID: PMC9405554 DOI: 10.3390/biomedicines10081960] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/05/2022] [Accepted: 08/06/2022] [Indexed: 11/18/2022] Open
Abstract
While more than half of non-Hodgkin lymphomas (NHL) can be cured with modern frontline chemoimmunotherapy regimens, outcomes of relapsed and/or refractory (r/r) disease in subsequent lines remain poor, particularly if considered ineligible for hematopoietic stem cell transplantation. Hence, r/r NHLs represent a population with a high unmet medical need. This therapeutic gap has been partially filled by adoptive immunotherapy. CD19-directed autologous chimeric antigen receptor (auto-CAR) T cells have been transformative in the treatment of patients with r/r B cell malignancies. Remarkable response rates and prolonged remissions have been achieved in this setting, leading to regulatory approval from the U.S. Food and Drug Administration (FDA) of four CAR T cell products between 2017 and 2021. This unprecedented success has created considerable enthusiasm worldwide, and autologous CAR T cells are now being moved into earlier lines of therapy in large B cell lymphoma. Herein, we summarize the current practice and the latest progress of CD19 auto-CAR T cell therapy and the management of specific toxicities and discuss the place of allogeneic CAR T development in this setting.
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Affiliation(s)
- Semira Sheikh
- Department of Hematology, Universitätsspital Basel, 4031 Basel, Switzerland
| | - Denis Migliorini
- Department of Oncology, Hôpitaux Universitaires de Genève, 1205 Geneva, Switzerland
- Center for Translational Research in Oncohematology, University of Geneva, 1206 Geneva, Switzerland
| | - Noémie Lang
- Department of Oncology, Hôpitaux Universitaires de Genève, 1205 Geneva, Switzerland
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CAR T-cell therapy: which product for which patient? Blood 2022; 139:3673-3674. [PMID: 35771558 PMCID: PMC9247365 DOI: 10.1182/blood.2022016676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 04/18/2022] [Indexed: 11/20/2022] Open
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Oluwole OO, Liu R, Diakite I, Feng C, Patel A, Nourhussein I, Snider JT, Locke FL. Cost-effectiveness of axicabtagene ciloleucel versus lisocabtagene maraleucel for adult patients with relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy in the US. J Med Econ 2022; 25:541-551. [PMID: 35443867 DOI: 10.1080/13696998.2022.2065787] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
AIMS This study evaluated from a US payer perspective the cost-effectiveness of two chimeric antigen receptor T (CAR T) cell therapies, axicabtagene ciloleucel (axi-cel) versus lisocabtagene maraleucel (liso-cel), for the treatment of adult patients with relapsed or refractory (r/r) large B-cell lymphoma (LBCL) following two or more systemic therapy lines. METHODS We developed a 3-state (i.e., pre-progression, post-progression, death) partitioned survival model to estimate patients' lifetime outcomes. Mixture cure models were used for survival extrapolation to account for long-term remission. Survival inputs were based on a matching-adjusted indirect comparison (MAIC) that reweighted the ZUMA-1 population (receiving axi-cel) to match patient characteristics in TRANSCEND-NHL-001 (assessing liso-cel). Costs included apheresis, drug acquisition, and administration for conditioning chemotherapy and CAR T therapies, monitoring, transplant, hospitalization, adverse events, routine care, and terminal care, per published literature and databases. Utilities were derived from ZUMA-1 and literature. Deterministic and probabilistic sensitivity analyses were conducted. RESULTS In the base case, axi-cel was associated with more QALYs (7.76 vs. 5.94) and greater costs overall ($611,440 vs. $597,174) than liso-cel, at $7,843/QALY gained. The incremental costs (+$14,266) were largely driven by higher routine care costs (+$18,596) due to longer survival and hospitalization (+$10,993) but partially offset by reduced costs of CAR T acquisition (‒$11,300) and terminal care (‒$4,025). Sensitivity analyses consistently suggested robustness of base-case results. LIMITATIONS This study relied on an MAIC in which trial design differences and unobserved confounders could not be accounted for. Future real-world studies for recently approved CAR T are warranted to validate our results. Due to a lack of data, we assumed equivalent use of transplants and treatment for B-cell aplasia between the two therapies based on clinicians' opinions. CONCLUSIONS In the US, axi-cel is a potentially cost-effective treatment option compared with liso-cel for adult patients with r/r LBCL after two or more systemic therapy lines.
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Affiliation(s)
| | | | | | | | - Anik Patel
- Kite, A Gilead Company, Santa Monica, CA, USA
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