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Kurte MS, Siefen AC, Jakobs F, Poos T, von Tresckow J, von Tresckow B, Reinhardt HC, Kron F. Time-dependent cost comparison and health economic impact analysis of second-line interventions for transplant-ineligible patients with relapsed or refractory diffuse large B cell lymphoma. Eur J Haematol 2024; 113:371-383. [PMID: 38853698 DOI: 10.1111/ejh.14248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 05/14/2024] [Accepted: 05/16/2024] [Indexed: 06/11/2024]
Abstract
OBJECTIVES Novel interventions (axicabtagene ciloleucel [axi-cel], lisocabtagene maraleucel [liso-cel], tafasitamab-lenalidomide [Tafa-L], polatuzumab-rituximab-bendamustine [pola-BR]) improve clinical outcomes in second-line (2 L) treatment of transplant-ineligible patients with early relapse or refractory (R/R) diffuse large B cell lymphoma (DLBCL). The costs vary depending on the respective treatment regimen and the treatment duration, difficult comparability in reimbursement decisions. The objective was to analyze the health economic impacts of novel 2 L interventions and conventional immunochemotherapies (bendamustine-rituximab [BR], rituximab-gemcitabine-oxaliplatin [R-GemOx]) from a German healthcare payer's perspective as a function of treatment duration. METHODS An economic model was developed to compare treatment costs of 2 L interventions depending on the treatment duration. Treatment duration was measured by progression-free survival (PFS), identified based on a systematic review. Total and average costs were calculated over 5 years to evaluate incremental costs at median PFS for each intervention. RESULTS Average costs per month at median PFS ranged from €2846 (95% CI: 5067-1641) to €40 535 (95% CI: 91180-N/A) for BR and liso-cel, respectively. Incremental costs at the lowest median PFS (R-GemOx: 5.3 months) revealed -€664, €5560, €11 817, €53 145, and €67 745 for BR, Tafa-L, pola-BR, axi-cel, and liso-cel as compared to R-GemOx, respectively. CONCLUSIONS Analyses uncovered a variation of incremental costs of 2 L transplant-ineligible DLBCL interventions as a function of time leading to amortization of high-priced interventions.
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MESH Headings
- Humans
- Lymphoma, Large B-Cell, Diffuse/economics
- Lymphoma, Large B-Cell, Diffuse/therapy
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/mortality
- Cost-Benefit Analysis
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/economics
- Models, Economic
- Health Care Costs
- Drug Resistance, Neoplasm
- Recurrence
- Treatment Outcome
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Affiliation(s)
- Melina Sophie Kurte
- Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
- VITIS Healthcare Group, Cologne, Germany
| | - Ann-Cathrine Siefen
- Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
- VITIS Healthcare Group, Cologne, Germany
| | - Florian Jakobs
- Department of Haematology and Stem Cell Transplantation, Faculty of Medicine and University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Tabea Poos
- VITIS Healthcare Group, Cologne, Germany
| | - Julia von Tresckow
- Department of Haematology and Stem Cell Transplantation, Faculty of Medicine and University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Bastian von Tresckow
- Department of Haematology and Stem Cell Transplantation, West German Cancer Center and German Cancer consortium (DKTK partner site Essen), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Hans Christian Reinhardt
- Department of Haematology and Stem Cell Transplantation, Faculty of Medicine and University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Florian Kron
- VITIS Healthcare Group, Cologne, Germany
- Department I of Internal Medicine, Center for Integrated Oncology (CIO Cologne), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- FOM University of Applied Sciences, Essen, Germany
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2
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Sesques P, Kirkwood AA, Kwon M, Rejeski K, Jain MD, Di Blasi R, Brisou G, Gros FX, le Bras F, Bories P, Choquet S, Rubio MT, Iacoboni G, O'Reilly M, Casasnovas RO, Bay JO, Mohty M, Joris M, Abraham J, Castilla Llorente C, Loschi M, Carras S, Chauchet A, La Rochelle LD, Hermine O, Guidez S, Cony-Makhoul P, Fogarty P, Le Gouill S, Morschhauser F, Gastinne T, Cartron G, Subklewe M, Locke FL, Sanderson R, Barba P, Houot R, Bachy E. Novel prognostic scoring systems for severe CRS and ICANS after anti-CD19 CAR T cells in large B-cell lymphoma. J Hematol Oncol 2024; 17:61. [PMID: 39107847 PMCID: PMC11305039 DOI: 10.1186/s13045-024-01579-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 07/19/2024] [Indexed: 08/10/2024] Open
Abstract
Autologous anti-CD19 chimeric antigen receptor (CAR) T cells are now used in routine practice for relapsed/refractory (R/R) large B-cell lymphoma (LBCL). Severe (grade ≥ 3) cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity (ICANS) are still the most concerning acute toxicities leading to frequent intensive care unit (ICU) admission, prolonging hospitalization, and adding significant cost to treatment. We report on the incidence of CRS and ICANS and the outcomes in a large cohort of 925 patients with LBCL treated with axicabtagene ciloleucel (axi-cel) or tisagenlecleucel (tisa-cel) in France based on patient data captured through the DESCAR-T registry. CRS of any grade occurred in 778 patients (84.1%), with 74 patients (8.0%) with grade 3 CRS or higher, while ICANS of any grade occurred in 375 patients (40.5%), with 112 patients (12.1%) with grade ≥ 3 ICANS. Based on the parameters selected by multivariable analyses, two independent prognostic scoring systems (PSS) were derived, one for grade ≥ 3 CRS and one for grade ≥ 3 ICANS. CRS-PSS included bulky disease, a platelet count < 150 G/L, a C-reactive protein (CRP) level > 30 mg/L and no bridging therapy or stable or progressive disease (SD/PD) after bridging. Patients with a CRS-PSS score > 2 had significantly higher risk to develop grade ≥ 3 CRS. ICANS-PSS included female sex, low level of platelets (< 150 G/L), use of axi-cel and no bridging therapy or SD/PD after bridging. Patients with a CRS-PSS score > 2 had significantly higher risk to develop grade ≥ 3 ICANS. Both scores were externally validated in international cohorts of patients treated with tisa-cel or axi-cel.
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MESH Headings
- Humans
- Immunotherapy, Adoptive/adverse effects
- Immunotherapy, Adoptive/methods
- Male
- Female
- Middle Aged
- Antigens, CD19/immunology
- Prognosis
- Lymphoma, Large B-Cell, Diffuse/therapy
- Lymphoma, Large B-Cell, Diffuse/immunology
- Cytokine Release Syndrome/etiology
- Aged
- Adult
- Neurotoxicity Syndromes/etiology
- Biological Products/therapeutic use
- Biological Products/adverse effects
- France
- Aged, 80 and over
- Receptors, Antigen, T-Cell
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Affiliation(s)
- Pierre Sesques
- Hematology Department, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69410, Pierre Bénite, Lyon, France
| | - Amy A Kirkwood
- Cancer Research UK & UCL Cancer Trials Centre, UCL Cancer Institute, University College London, London, UK
| | - Mi Kwon
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Kai Rejeski
- Department of Medicine III - Hematology/Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Michael D Jain
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, USA
| | | | - Gabriel Brisou
- Hematology Department, Institut Paoli Calmettes, Marseille, France
| | | | - Fabien le Bras
- Hematology Department, Hôpital Henri Mondor, Créteil, France
| | - Pierre Bories
- Hematology Department, CHU de Toulouse, Toulouse, France
| | - Sylvain Choquet
- Hematology Department, Hôpital de la Pitié Salpêtrière and AP-HP Sorbonne Université, Paris, France
| | | | - Gloria Iacoboni
- Department of Hematology, University Hospital Vall d'Hebron, Barcelona, Spain
- Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Maeve O'Reilly
- Department of Haematology, University College London Hospitals, London, UK
| | | | | | - Mohamad Mohty
- Hematology Department, Hôpital Saint Antoine, Inserm UMRs 938, Sorbonne University, Paris, France
| | | | - Julie Abraham
- Hematology Department, CHU de Limoges, Limoges, France
| | | | | | - Sylvain Carras
- Hematology Department, Institute for Advanced Biosciences (INSERM U1209, CNRS UMR 5309), CHU de Grenoble and University Grenoble-Alpes, La Tronche, France
| | | | | | | | | | | | | | | | - Franck Morschhauser
- Hematology Department, CHU de Lille, Lille, France
- ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille University, Lille, France
| | | | - Guillaume Cartron
- Hematology Department, CHU de Montpellier and UMR-CNRS, Montpellier, France
| | - Marion Subklewe
- Department of Medicine III - Hematology/Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Frederick L Locke
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, USA
| | - Robin Sanderson
- Department of Haematology, King's College Hospital, London, UK
| | - Pere Barba
- Department of Hematology, University Hospital Vall d'Hebron, Barcelona, Spain
- Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Roch Houot
- Hematology Department, CHU de Rennes, Rennes, France
| | - Emmanuel Bachy
- Hematology Department, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69410, Pierre Bénite, Lyon, France.
- Lymphoma Immuno-Biology, CIRI, Inserm U1111, Lyon, France.
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3
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O'Reilly MA, Wilson W, Burns D, Kuhnl A, Seymour F, Uttenthal B, Besley C, Alajangi R, Creasey T, Paneesha S, Elliot J, Gonzalez Arias C, Iyengar S, Wilson MR, Delaney A, Rubio L, Lambert J, Begg K, Boyle S, Cheok KPL, Collins GP, Roddie C, Johnson R, Sanderson R. Brexucabtagene autoleucel for relapsed or refractory mantle cell lymphoma in the United Kingdom: A real-world intention-to-treat analysis. Hemasphere 2024; 8:e87. [PMID: 38873532 PMCID: PMC11170269 DOI: 10.1002/hem3.87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/12/2024] [Accepted: 05/01/2024] [Indexed: 06/15/2024] Open
Abstract
Brexucabtagene autoleucel (brexu-cel) is an autologous CD19 CAR T-cell product, approved for relapsed/refractory (r/r) mantle cell lymphoma (MCL). In ZUMA-2, brexu-cel demonstrated impressive responses in patients failing ≥2 lines, including a bruton's tyrosine kinase inhibitor, with an overall and complete response rate of 93% and 67%, respectively. Here, we report our real-world intention-to-treat (ITT) outcomes for brexu-cel in consecutive, prospectively approved patients, from 12 institutions in the United Kingdom between February 2021 and June 2023, with a focus on feasibility, efficacy, and tolerability. Of 119 approved, 104 underwent leukapheresis and 83 received a brexu-cel infusion. Progressive disease (PD) and/or manufacturing (MF) were the most common reasons for failure to reach harvest and/or infusion. For infused patients, best overall and complete response rates were 87% and 81%, respectively. At a median follow-up of 13.3 months, median progression-free survival (PFS) for infused patients was 21 months (10.1-NA) with a 6- and 12-month PFS of 82% (95% confidence interval [CI], 71-89) and 62% (95% CI, 49-73), respectively. ≥Grade 3 cytokine release syndrome and neurotoxicity occurred in 12% and 22%, respectively. On multivariate analysis, inferior PFS was associated with male sex, bulky disease, ECOG PS > 1 and previous MF. Cumulative incidence of non-relapse mortality (NRM) was 6%, 15%, and 25% at 6, 12, and 24 months, respectively, and mostly attributable to infection. Outcomes for infused patients in the UK are comparable to ZUMA-2 and other real-world reports. However, ITT analysis highlights a significant dropout due to PD and/or MF. NRM events warrant further attention.
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Affiliation(s)
- Maeve A. O'Reilly
- University College London HospitalLondonUK
- University College London Cancer InstituteLondonUK
| | - William Wilson
- University College London and CRUK Cancer Trials CentreLondonUK
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Claire Roddie
- University College London HospitalLondonUK
- University College London Cancer InstituteLondonUK
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4
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Gagelmann N, Bishop M, Ayuk F, Bethge W, Glass B, Sureda A, Pasquini MC, Kröger N. Axicabtagene Ciloleucel versus Tisagenlecleucel for Relapsed or Refractory Large B Cell Lymphoma: A Systematic Review and Meta-Analysis. Transplant Cell Ther 2024; 30:584.e1-584.e13. [PMID: 38281590 DOI: 10.1016/j.jtct.2024.01.074] [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: 10/24/2023] [Revised: 12/28/2023] [Accepted: 01/23/2024] [Indexed: 01/30/2024]
Abstract
Axicabtagene ciloleucel (axi-cel) and tisagenlecleucel (tisa-cel) are CD19-directed chimeric antigen receptor T cell (CAR-T) therapies approved for relapsed/refractory aggressive large B cell lymphoma (LBCL). Significant costs and complex manufacturing underscore the importance of evidence-based counseling regarding the outcomes of these treatments. With the aim of examining the efficacy and safety of axi-cel versus tisa-cel in patients with relapsed/refractory aggressive LBCL, we performed a systematic literature search of comparative studies evaluating outcomes in relapsed/refractory aggressive LBCL after treatment with axi-cel or tisa-cel. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) for response, progression-free survival (PFS), overall survival (OS), cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and hematotoxicity. Meta-analysis and meta-regression were used to generate summary statistics. A total of 2372 participants were included in the 8 studies in our analysis. The dropout rate between apheresis and infusion was 13% for axi-cel versus 18% for tisa-cel, and the median time from apheresis to infusion was 32 days versus 45 days. Axi-cel showed higher odds for a complete response (OR, 1.65; P < .001) and was associated with higher odds for PFS at 1 year after infusion (OR, .60; P < .001). OS appeared to be improved with axi-cel (OR, .84; 95% CI, .68 to 1.02; P = .08), whereas the cumulative incidence of nonrelapse mortality (NRM) was 11.5% for axi-cel versus 3.7% for tisa-cel (P = .002). The main predictors for survival were lactate dehydrogenase level, Eastern Cooperative Oncology Group Performance Status, and response to bridging, and axi-cel maintained superior efficacy even in elderly patients. In terms of safety, axi-cel was associated with significantly higher odds of any-grade CRS (OR, 3.23; P < .001), but not of grade ≥3 CRS (P = .92). Axi-cel was associated with significantly higher odds of severe ICANS grade ≥3 (OR, 4.03; P < .001). In terms of hematotoxicity, axi-cel was significantly associated with higher odds of severe neutropenia at 1 month after infusion (OR, 2.06; P = .003). As a result, axi-cel was associated with significantly greater resource utilization, including prolonged hospital stay, more frequent intensive care admission, and use of agents such as tocilizumab for toxicity management. We provide strong evidence of the greater efficacy of axi-cel versus tisa-cel in relapsed/refractory aggressive LBCL. The higher toxicity and NRM seen with axi-cel might not counterbalance the overall results, highlighting the need for timely intervention and careful selection of patients, balancing resource utilization and clinical benefit.
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Affiliation(s)
- Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Michael Bishop
- The David and Etta Jonas Center for Cellular Therapy, University of Chicago, Chicago, Illinois
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Bethge
- Department of Hematology and Oncology, University Hospital Tuebingen, Tuebingen, Germany
| | - Bertram Glass
- Department of Hematology and Cell Therapy, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Anna Sureda
- Bellvitge Institute for Biomedical Research, Universitat de Barcelona, Hematology Department, Institut Català d'Oncologia-Hospitalet, Barcelona, Spain
| | - Marcelo C Pasquini
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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5
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Qian H, Yang X, Zhang T, Zou P, Zhang Y, Tian W, Mao Z, Wei J. Improving the safety of CAR-T-cell therapy: The risk and prevention of viral infection for patients with relapsed or refractory B-cell lymphoma undergoing CAR-T-cell therapy. Am J Hematol 2024; 99:662-678. [PMID: 38197307 DOI: 10.1002/ajh.27198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/05/2023] [Accepted: 12/15/2023] [Indexed: 01/11/2024]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy, an innovative immunotherapeutic against relapsed/refractory B-cell lymphoma, faces challenges due to frequent viral infections. Despite this, a comprehensive review addressing risk assessment, surveillance, and treatment management is notably absent. This review elucidates immune response compromises during viral infections in CAR-T recipients, collates susceptibility risk factors, and deliberates on preventive strategies. In the post-pandemic era, marked by the Omicron variant, new and severe threats to CAR-T therapy emerge, necessitating exploration of preventive and treatment measures for COVID-19. Overall, the review provides recommendations for viral infection prophylaxis and management, enhancing CAR-T product safety and recipient survival.
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Affiliation(s)
- Hu Qian
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xingcheng Yang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tingting Zhang
- Cancer Center, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Sino-German Joint Oncological Research Laboratory, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Ping Zou
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yicheng Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Weiwei Tian
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Sino-German Joint Oncological Research Laboratory, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Zekai Mao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jia Wei
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Sino-German Joint Oncological Research Laboratory, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, China
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6
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Neuendorff NR, Khan A, Ullrich F, Yates S, Devarakonda S, Lin RJ, von Tresckow B, Cordoba R, Artz A, Rosko AE. Cellular therapies in older adults with hematological malignancies: A case-based, state-of-the-art review. J Geriatr Oncol 2024; 15:101734. [PMID: 38430810 DOI: 10.1016/j.jgo.2024.101734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 11/05/2023] [Accepted: 02/19/2024] [Indexed: 03/05/2024]
Abstract
Cellular therapies, including autologous stem cell transplant (ASCT), allogeneic hematopoietic cell transplantation (alloHCT), and chimeric antigen receptor- (CAR-) T cell therapies are essential treatment modalities for many hematological malignancies. Although their use in older adults has substantially increased within the past decades, cellular therapies represent intensive treatment approaches that exclude a large percentage of older adults due to comorbidities and frailty. Under- and overtreatment in older adults with hematologic malignancy is a challenge and many treatment decisions are influenced by chronologic age. The advent of efficient and well-tolerated newer treatment approaches for multiple myeloma has challenged the role of ASCT. In the modern era, there are no randomized clinical trials of transplant versus non-transplant strategies for patients ≥65 years. Nonetheless, ASCT is feasible for selected older patients and does not result in long-term compromise in quality of life. AlloHCT is the only curative approach for acute myeloid leukemia of intermediate and unfavourable risk but carries a significant risk for non-relapse mortality depending on comorbidities, general fitness, and transplant-specific characteristics, such as intensity of conditioning and donor choice. However, alloHCT is feasible in appropriately-selected older adults. Early referral for evaluation is strongly encouraged as this is the most obvious barrier. CAR-T cell therapies have shown unprecedented clinical efficacy and durability in relapsed and refractory diffuse large B cell lymphoma. Its use is well tolerated in older adults, although evidence comes from limited case numbers. Whether patients who are deemed unfit for ASCT qualify for CAR-T cell therapy remains elusive, but the tolerability and efficacy of CAR-T cell therapy appears promising, especially for older patients. The evidence from randomized trials is strong in favor of using a comprehensive geriatric assessment (CGA) to reduce treatment-related toxicities and guide treatment intensity in the care for solid tumors; its use for evaluation of cellular therapies is less evidence-based. However, CGA can provide useful information on patients' fitness, resilient mechanisms, and reveal potential optimization strategies for compensating for vulnerabilities. In this narrative review, we will discuss key questions on cellular therapies in older adults based on illustrative patient cases.
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Affiliation(s)
- Nina Rosa Neuendorff
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, D-45147 Essen, Germany.
| | - Abdullah Khan
- Department of Hematology, The Ohio State University, James Comprehensive Cancer Center, Columbus, OH, United States of America
| | - Fabian Ullrich
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, D-45147 Essen, Germany
| | - Samuel Yates
- Department of Internal Medicine, Section of Hematology and Oncology, University of Chicago, Chicago, IL, United States of America
| | - Srinivas Devarakonda
- Department of Hematology, The Ohio State University, James Comprehensive Cancer Center, Columbus, OH, United States of America
| | - Richard J Lin
- Adult Bone Marrow Transplantation (BMT) Service, Cellular Therapy Service, Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Bastian von Tresckow
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, D-45147 Essen, Germany
| | - Raul Cordoba
- Lymphoma Unit, Department of Hematology, Health Research Institute IIS-FJD, Fundacion Jimenez Diaz University Hospital, Madrid, Spain
| | - Andrew Artz
- Division of Leukemia, Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, USA
| | - Ashley E Rosko
- Department of Hematology, The Ohio State University, James Comprehensive Cancer Center, Columbus, OH, United States of America
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7
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Galli E, Fresa A, Bellesi S, Metafuni E, Maiolo E, Pansini I, Frioni F, Autore F, Limongiello MA, Innocenti I, Giammarco S, Chiusolo P, Zini G, Sorà F. Hematopoiesis and immune reconstitution after CD19 directed chimeric antigen receptor T-cells (CAR-T): A comprehensive review on incidence, risk factors and current management. Eur J Haematol 2024; 112:184-196. [PMID: 37491951 DOI: 10.1111/ejh.14052] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 07/27/2023]
Abstract
Impaired function of hematopoiesis after treatment with chimeric antigen T-cells (CAR-T) is a frequent finding and can interest a wide range of patients, regardless of age and underlying disease. Trilinear cytopenias, as well as hypogammaglobulinemia, B-cell aplasia, and T-cell impairment, can severely affect the infectious risk of CAR-T recipients, as well as their quality of life. In this review, we provide an overview of defects in hematopoiesis after CAR-T, starting with a summary of different definitions and thresholds. We then move to summarize the main pathogenetic mechanisms of cytopenias, and we offer insight into cytomorphological aspects, the role of clonal hematopoiesis, and the risk of secondary myeloid malignancies. Subsequently, we expose the major findings and reports on T-cell and B-cell quantitative and functional impairment after CAR-T. Finally, we provide an overview of current recommendations and leading experiences regarding the management of cytopenias and defective B- and T-cell function.
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Affiliation(s)
- Eugenio Galli
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alberto Fresa
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Silvia Bellesi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Elisabetta Metafuni
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Elena Maiolo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Ilaria Pansini
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Filippo Frioni
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Autore
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Assunta Limongiello
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Idanna Innocenti
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Sabrina Giammarco
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Patrizia Chiusolo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gina Zini
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Federica Sorà
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
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8
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Houot R, Bachy E, Cartron G, Gros FX, Morschhauser F, Oberic L, Gastinne T, Feugier P, Duléry R, Thieblemont C, Joris M, Jardin F, Choquet S, Casasnovas O, Brisou G, Cheminant M, Bay JO, Gutierrez FL, Menard C, Tarte K, Delfau MH, Portugues C, Itti E, Palard-Novello X, Blanc-Durand P, Al Tabaa Y, Bailly C, Laurent C, Lemonnier F. Axicabtagene ciloleucel as second-line therapy in large B cell lymphoma ineligible for autologous stem cell transplantation: a phase 2 trial. Nat Med 2023; 29:2593-2601. [PMID: 37710005 PMCID: PMC10579056 DOI: 10.1038/s41591-023-02572-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/29/2023] [Indexed: 09/16/2023]
Abstract
Axicabtagene ciloleucel (axi-cel) demonstrated superior efficacy compared to standard of care as second-line therapy in patients with high-risk relapsed/refractory (R/R) large B cell lymphoma (LBCL) considered eligible for autologous stem cell transplantation (ASCT); however, in clinical practice, roughly half of patients with R/R LBCL are deemed unsuitable candidates for ASCT. The efficacy of axi-cel remains to be ascertained in transplant-ineligible patients. ALYCANTE, an open-label, phase 2 study, evaluated axi-cel as a second-line therapy in 62 patients with R/R LBCL who were considered ineligible for ASCT. The primary end point was investigator-assessed complete metabolic response at 3 months from the axi-cel infusion. Key secondary end points included progression-free survival, overall survival and safety. The study met its primary end point with a complete metabolic response of 71.0% (95% confidence interval, 58.1-81.8%) at 3 months. With a median follow-up of 12.0 months (range, 2.1-17.9), median progression-free survival was 11.8 months (95% confidence interval, 8.4-not reached) and overall survival was not reached. There was no unexpected toxicity. Grade 3-4 cytokine release syndrome and neurologic events occurred in 8.1% and 14.5% of patients, respectively. These results support axi-cel as second-line therapy in patients with R/R LBCL ineligible for ASCT. ClinicalTrials.gov Identifier: NCT04531046 .
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Affiliation(s)
- Roch Houot
- Department of Hematology, University Hospital of Rennes, UMR U1236, INSERM, University of Rennes, French Blood Establishment, Rennes, France.
| | - Emmanuel Bachy
- Department of Hematology, Lyon Sud Hospital Center, INSERM U1111, Lyon, France
| | - Guillaume Cartron
- Department of Hematology, University Hospital of Montpellier, UMR-CNRS 5535, Montpellier, France
| | - François-Xavier Gros
- Department of Clinical Hematology and Cellular Therapy, University Hospital of Bordeaux, Bordeaux, France
| | | | - Lucie Oberic
- Department of Hematology, Cancer University Institute of Toulouse Oncopole, Toulouse, France
| | - Thomas Gastinne
- Department of Hematology, University Hospital of Nantes, Nantes, France
| | - Pierre Feugier
- Department of Hematology, University Hospital of Nancy, INSERM 1256, University of Lorraine, Vandœuvre-lès-Nancy, France
| | - Rémy Duléry
- Department of Clinical Hematology and Cellular Therapy, Sorbonne University, Saint-Antoine Hospital, AP-HP, INSERM UMR938, Paris, France
| | | | - Magalie Joris
- Department of Hematology, University Hospital of Amiens, Amiens, France
| | - Fabrice Jardin
- Department of Clinical Hematology, Henri Becquerel Center, INSERM U1245, Rouen, France
| | - Sylvain Choquet
- Department of Hematology, University Hospital Pitié Salpêtrière, AP-HP, Sorbonne University, Paris, France
| | - Olivier Casasnovas
- Department of Clinical Hematology, Dijon University Hospital, INSERM UMR1231, Dijon, France
| | - Gabriel Brisou
- Department of Hematology, Institut Paoli-Calmettes, Marseille, France
| | - Morgane Cheminant
- Department of Clinical Hematology, Necker-Enfants Malades University Hospital, AP-HP, INSERM UMR1163, Paris, France
| | - Jacques-Olivier Bay
- Department of Clinical Hematology and Cellular Therapy, Clermont-Ferrand University Hospital Center, Clermont-Ferrand, France
| | | | - Cédric Menard
- French Blood Establishment and SITI Laboratory, UMR U1236, INSERM, University of Rennes, University Hospital Center of Rennes, Rennes, France
| | - Karin Tarte
- French Blood Establishment and SITI Laboratory, UMR U1236, INSERM, University of Rennes, University Hospital Center of Rennes, Rennes, France
| | | | - Cédric Portugues
- Department of Biostatistics, LYSARC, Lyon-Sud Hospital, Pierre-Bénite, France
| | - Emmanuel Itti
- Department of Nuclear Medicine, Henri Mondor Hospital, Créteil, France
| | - Xavier Palard-Novello
- Department of Nuclear Medicine, University of Rennes, CLCC Eugène Marquis, INSERM, Rennes, France
| | - Paul Blanc-Durand
- Department of Nuclear Medicine, CHU H. Mondor, U-PEC, AP-HP, Créteil, France
| | - Yassine Al Tabaa
- Scintidoc Nuclear Medicine Center, Clinique Clémentville, Montpellier, France
| | - Clément Bailly
- Nantes-Angers Cancer Research Center CRCI2NA, University of Nantes, INSERM UMR1307, CNRS-ERL6075, Nantes, France
| | - Camille Laurent
- Department of Pathology, Cancer University Institute of Toulouse Oncopole, CHU Toulouse, CRCT INSERM U1037, Toulouse, France
| | - François Lemonnier
- Lymphoid Malignancies Unit, Henri Mondor Hospital, Mondor Institute for Biomedical Research, INSERM U955, University Paris-Est, Créteil, France
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9
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Abdulhaq H, Hwang A, Mahmood O. Targeted Treatment of Adults with Relapsed or Refractory Diffuse Large B-Cell Lymphoma (DLBCL): Tafasitamab in Context. Onco Targets Ther 2023; 16:617-629. [PMID: 37492075 PMCID: PMC10364833 DOI: 10.2147/ott.s372783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 07/06/2023] [Indexed: 07/27/2023] Open
Abstract
The outcomes of Relapsed/Refractory (R/R) Diffuse Large B-cell lymphoma have been historically poor. The recent development of several novel therapies including CD19 directed agents has improved the prognosis of this disease significantly. Chimeric antigen receptor (CAR) T-cell therapy has drastically changed the treatment of R/R DLBCL, but it is still associated with significant barriers and limited access. Tafasitamab (an anti-CD19 engineered monoclonal antibody), in addition to lenalidomide, has shown significant efficacy with exceptionally durable responses in patients with R/R DLBCL who are ineligible for autologous stem cell transplantation (ASCT). Tafasitamab-lenalidomide and certain other therapies (ie, antibody-drug conjugates and bispecific antibodies) are important treatment options for patients who are ineligible for CAR-T due to co-morbidities or lack of access, and patients with rapid progression of disease who are unable to wait for manufacturing of CAR-T. This review will thus discuss currently approved and recently studied targeted treatment options for patients with R/R DLBCL with an emphasis on CAR-T alternative options, particularly Tafasitamab-lenalidomide.
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Affiliation(s)
- Haifaa Abdulhaq
- Division of Hematology/Oncology, University of California San Francisco, Fresno, CA, USA
| | - Andrew Hwang
- Division of Hematology/Oncology, University of California San Francisco, Fresno, CA, USA
| | - Omar Mahmood
- Division of Hematology/Oncology, University of California San Francisco, Fresno, CA, USA
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