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Lei M, Li Q, O'Day K, Meyer K, Wang A, Jun MP. Practice efficiency and total cost of care with bispecifics and CAR-T in relapsed/refractory diffuse large B-cell lymphoma: an institutional perspective. Future Oncol 2024:1-13. [PMID: 38913826 DOI: 10.1080/14796694.2024.2354157] [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: 03/08/2024] [Accepted: 05/08/2024] [Indexed: 06/26/2024] Open
Abstract
Aim: Novel treatment options for relapsed/refractory diffuse large B-cell lymphoma include T-cell targeting therapies. Practice efficiency and cost are important for informed treatment decisions.Materials/methods: An institutional decision-maker cost model was developed for 6-month, 1-year and median cycles of treatment time horizons comparing practice efficiency and costs of epcoritamab vs glofitamab and axicabtagene ciloleucel (axi-cel).Results: Overall, epcoritamab required the shortest personnel and chair time, except over 1 year (second shortest chair time). Across all time horizons, epcoritamab was cost-saving vs axi-cel and had similar costs to glofitamab on a per-month basis.Conclusion: Epcoritamab reduced personnel and chair time. Additionally, epcoritamab was cost-saving vs axi-cel and had similar costs to glofitamab on a per-month basis.
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Affiliation(s)
- Matthew Lei
- Pharmacy Department, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Qianyi Li
- Market Access & Healthcare Consulting, Cencora, Conshohocken, PA 19428, USA
| | - Ken O'Day
- Market Access & Healthcare Consulting, Cencora, Conshohocken, PA 19428, USA
| | - Kellie Meyer
- Market Access & Healthcare Consulting, Cencora, Conshohocken, PA 19428, USA
| | - Anthony Wang
- Health Economics and Outcomes Research, AbbVie Inc., North Chicago, IL 60064, USA
| | - Monika P Jun
- Center for Outcomes Research, Real-world Evidence and Epidemiology, Genmab US, Inc., Plainsboro, NJ 08536, USA
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2
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Lin SW, Shapouri S, Parisé H, Bercaw E, Wu M, Kim E, Matasar M. Budget Impact of Introducing Fixed-Duration Mosunetuzumab for the Treatment of Relapsed or Refractory Follicular Lymphoma After Two or More Lines of Systemic Therapy in the USA. PHARMACOECONOMICS 2024; 42:569-582. [PMID: 38300452 DOI: 10.1007/s40273-024-01358-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/14/2024] [Indexed: 02/02/2024]
Abstract
OBJECTIVE This study aimed to assess the budget impact of introducing fixed-duration mosunetuzumab as a treatment option for adult patients with relapsed or refractory follicular lymphoma after at least two prior systemic therapies and to estimate the total cumulative costs per patient in the USA. METHODS A 3-year budget impact model was developed for a hypothetical 1-million-member cohort enrolled in a mixed commercial/Medicare health plan. Comparators were: axicabtagene ciloleucel, tisagenlecleucel, tazemetostat, rituximab plus lenalidomide, copanlisib, and older therapies (rituximab or obinutuzumab ± chemotherapy). Costs per patient comprised treatment-associated costs including the drug, its administration, adverse events, and routine care. Dosing and safety data were ascertained from respective package inserts and clinical trial data. Drug costs (March 2023) were estimated based on the average wholesale acquisition cost reported in AnalySource®, and all other costs were based on published sources and inflated to 2022 US dollars. Market shares were obtained from Genentech internal projections and expert opinion. Budget impact outcomes were presented on a per-member per-month basis. RESULTS Compared with a scenario without mosunetuzumab, its introduction over 3 years resulted in a budget increase of $69,812 (1% increase) and an average per-member per-month budget impact of $0.0019. Among the newer therapies, mosunetuzumab had the second-lowest cumulative per patient cost (mosunetuzumab = $202,039; axicabtagene ciloleucel = $505,845; tisagenlecleucel = $476,293; rituximab plus lenalidomide = $263,520; tazemetostat = $250,665; copanlisib = $127,293) and drug costs, and its introduction only increased total drug costs by 0.1%. By year 3, the cumulative difference in the per patient cost with mosunetuzumab was -$303,805 versus axicabtagene ciloleucel, -$274,254 versus tisagenlecleucel, -$61,481 versus rituximab plus lenalidomide, -$48,625 versus tazemetostat, and $74,747 versus copanlisib. Older therapies were less costly with 3-year cumulative costs that ranged from $36,512 to $147,885. CONCLUSIONS Over 3 years, the estimated cumulative per patient cost of mosunetuzumab is lower than most available newer therapies, resulting in a small increase in the budget after its formulary adoption for the treatment of relapsed or refractory follicular lymphoma.
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Affiliation(s)
| | | | | | | | - Mei Wu
- Genentech, Inc., South San Francisco, CA, USA
| | - Eunice Kim
- Genentech, Inc., South San Francisco, CA, USA
| | - Matthew Matasar
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
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3
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Zheng N, Long Y, Bai Z, Li J, Wang H, Song DD, Liu HL, Shi JH, Zhao S. Melatonin as an immunomodulator in CD19-targeting CAR-T cell therapy: managing cytokine release syndrome. J Transl Med 2024; 22:58. [PMID: 38221609 PMCID: PMC10789006 DOI: 10.1186/s12967-023-04779-z] [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: 09/04/2023] [Accepted: 11/28/2023] [Indexed: 01/16/2024] Open
Abstract
BACKGROUND Chimeric antigen receptor CAR-T cell therapies have ushered in a new era of treatment for specific blood cancers, offering unparalleled efficacy in cases of treatment resistance or relapse. However, the emergence of cytokine release syndrome (CRS) as a side effect poses a challenge to the widespread application of CAR-T cell therapies. Melatonin, a natural hormone produced by the pineal gland known for its antioxidant and anti-inflammatory properties, has been explored for its potential immunomodulatory effects. Despite this, its specific role in mitigating CAR-T cell-induced CRS remains poorly understood. METHODS In this study, our aim was to investigate the potential of melatonin as an immunomodulatory agent in the context of CD19-targeting CAR-T cell therapy and its impact on associated side effects. Using a mouse model, we evaluated the effects of melatonin on CAR-T cell-induced CRS and overall survival. Additionally, we assessed whether melatonin administration had any detrimental effects on the antitumor efficacy and persistence of CD19 CAR-T cells. RESULTS Our findings demonstrate that melatonin effectively mitigated the severity of CAR-T cell-induced CRS in the mouse model, leading to improved overall survival outcomes. Remarkably, melatonin administration did not compromise the antitumor effectiveness or persistence of CD19 CAR-T cells, indicating its compatibility with therapeutic goals. These results suggest melatonin's potential as an immunomodulatory compound to alleviate CRS without compromising the therapeutic benefits of CAR-T cell therapy. CONCLUSION The study's outcomes shed light on melatonin's promise as a valuable addition to the existing treatment protocols for CAR-T cell therapies. By attenuating CAR-T cell-induced CRS while preserving the therapeutic impact of CAR-T cells, melatonin offers a potential strategy for optimizing and refining the safety and efficacy profile of CAR-T cell therapy. This research contributes to the evolving understanding of how to harness immunomodulatory agents to enhance the clinical application of innovative cancer treatments.
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Affiliation(s)
- Na Zheng
- General Clinical Research Center, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yihao Long
- Department of Cell Biology, School of Basic Medical Sciences, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zixuan Bai
- Department of Cell Biology, School of Basic Medical Sciences, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jianing Li
- Department of Cell Biology, School of Basic Medical Sciences, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hongyu Wang
- Department of Cell Biology, School of Basic Medical Sciences, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Dan-Dan Song
- Central Laboratory, Hebei Collaborative Innovation Center of Tumor Microecological Metabolism Regulation, Hebei Key Laboratory of Cancer Radiotherapy and Chemotherapy, Affiliated Hospital of Hebei University, Baoding, Hebei, China
| | - Hong-Lin Liu
- Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China.
| | - Jian-Hong Shi
- Central Laboratory, Hebei Collaborative Innovation Center of Tumor Microecological Metabolism Regulation, Hebei Key Laboratory of Cancer Radiotherapy and Chemotherapy, Affiliated Hospital of Hebei University, Baoding, Hebei, China.
| | - Shuli Zhao
- General Clinical Research Center, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China.
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4
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Gong IY, Aminilari M, Landego I, Hueniken K, Zhou Q, Kuruvilla J, Hodgson DC. Comparative effectiveness of salvage chemotherapy regimens and chimeric antigen T-cell receptor therapies in relapsed and refractory diffuse large B cell lymphoma: a network meta-analysis of clinical trials. Leuk Lymphoma 2023; 64:1643-1654. [PMID: 37548344 DOI: 10.1080/10428194.2023.2234528] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/05/2023] [Accepted: 06/30/2023] [Indexed: 08/08/2023]
Abstract
The optimal salvage chemotherapy regimen (SC) for relapsed/refractory (R/R) diffuse large B-cell lymphoma (DLBCL) prior to autologous stem cell transplant remains unclear. Moreover, although chimeric antigen receptor T cell (CAR-T) therapies were recently approved for primary refractory DLBCL, head-to-head comparisons are lacking. We searched MEDLINE, EMBASE and CENTRAL to July 2022, for randomized trials that enrolled adult patients with R/R DLBCL and performed network meta-analyses (NMA) to assess the efficacy of SC and CAR-T therapies. NMA of SC (6 trials, 7 regimens, n = 1831) indicated that rituximab with gemcitabine, dexamethasone, cisplatin (R-GDP) improved OS and PFS over compared regimens. NMA of 3 CAR-T trials (n = 865) indicated that both axi-cel and liso-cel improved PFS over standard of care, with no difference in OS. Our results indicate that R-GDP may be preferred for R/R DLBCL over other SC compared. Longer follow-up is required for ongoing comparative survival analysis as data from CAR-T trials matures.
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Affiliation(s)
- Inna Y Gong
- Department of Radiation Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mahmood Aminilari
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Ivan Landego
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Katrina Hueniken
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Qianghua Zhou
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - John Kuruvilla
- Department of Radiation Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - David C Hodgson
- Department of Radiation Medicine, University of Toronto, Toronto, Ontario, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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5
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Boulch M, Cazaux M, Cuffel A, Ruggiu M, Allain V, Corre B, Loe-Mie Y, Hosten B, Cisternino S, Auvity S, Thieblemont C, Caillat-Zucman S, Bousso P. A major role for CD4 + T cells in driving cytokine release syndrome during CAR T cell therapy. Cell Rep Med 2023; 4:101161. [PMID: 37595589 PMCID: PMC10518592 DOI: 10.1016/j.xcrm.2023.101161] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 04/21/2023] [Accepted: 07/26/2023] [Indexed: 08/20/2023]
Abstract
Anti-CD19 chimeric antigen receptor (CAR) T cell therapy represents a breakthrough for the treatment of B cell malignancies. Yet, it can lead to severe adverse events, including cytokine release syndrome (CRS), which may require urgent clinical management. Whether interpatient variability in CAR T cell subsets contributes to CRS is unclear. Here, we show that CD4+ CAR T cells are the main drivers of CRS. Using an immunocompetent model of anti-CD19 CAR T cell therapy, we report that CD4+, but not CD8+, CAR T cells elicit physiological CRS-like manifestations associated with the release of inflammatory cytokines. In CAR T cell-treated patients, CRS occurrence and severity are significantly associated with high absolute values of CD4+ CAR T cells in the blood. CRS in mice occurs independently of CAR T cell-derived interferon γ (IFN-γ) but requires elevated tumor burden. Thus, adjusting the CD4:CD8 CAR T cell ratio to patient tumor load may help mitigate CAR T cell-associated toxicities.
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Affiliation(s)
- Morgane Boulch
- Institut Pasteur, Université Paris Cité, INSERM U1223, Dynamics of Immune Responses Unit, Équipe Labellisée Ligue Contre le Cancer, 75015 Paris, France
| | - Marine Cazaux
- Institut Pasteur, Université Paris Cité, INSERM U1223, Dynamics of Immune Responses Unit, Équipe Labellisée Ligue Contre le Cancer, 75015 Paris, France
| | - Alexis Cuffel
- Université Paris Cité, Hôpital Saint-Louis, AP-HP Nord, Laboratoire d'Immunologie, Paris, France; INSERM UMR976, Institut de Recherche St-Louis, Paris, France
| | - Mathilde Ruggiu
- Institut Pasteur, Université Paris Cité, INSERM U1223, Dynamics of Immune Responses Unit, Équipe Labellisée Ligue Contre le Cancer, 75015 Paris, France
| | - Vincent Allain
- Université Paris Cité, Hôpital Saint-Louis, AP-HP Nord, Laboratoire d'Immunologie, Paris, France; INSERM UMR976, Institut de Recherche St-Louis, Paris, France
| | - Béatrice Corre
- Institut Pasteur, Université Paris Cité, INSERM U1223, Dynamics of Immune Responses Unit, Équipe Labellisée Ligue Contre le Cancer, 75015 Paris, France
| | - Yann Loe-Mie
- Institut Pasteur, Université Paris Cité, Bioinformatics and Biostatistics HUB, 75015 Paris, France
| | - Benoit Hosten
- Université Paris Cité, INSERM, UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, 75006 Paris, France; Service de Pharmacie, Unité Claude Kellershohn - Radiopharmacie R&D, AP-HP, Hôpital Saint-Louis, 75475 Paris, France
| | - Salvatore Cisternino
- Université Paris Cité, INSERM, UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, 75006 Paris, France; Service de Pharmacie, AP-HP, Hôpital Necker, 75015 Paris, France
| | - Sylvain Auvity
- Université Paris Cité, INSERM, UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, 75006 Paris, France; Service de Pharmacie, AP-HP, Hôpital Necker, 75015 Paris, France
| | - Catherine Thieblemont
- Hémato-Oncologie, Hôpital Saint-Louis, AP-HP, Université Paris Cité, Inserm U1153, Paris, France
| | - Sophie Caillat-Zucman
- Université Paris Cité, Hôpital Saint-Louis, AP-HP Nord, Laboratoire d'Immunologie, Paris, France; INSERM UMR976, Institut de Recherche St-Louis, Paris, France
| | - Philippe Bousso
- Institut Pasteur, Université Paris Cité, INSERM U1223, Dynamics of Immune Responses Unit, Équipe Labellisée Ligue Contre le Cancer, 75015 Paris, France.
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6
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Ahmed N, Wesson W, Mushtaq MU, Porter DL, Nasta SD, Brower J, Bachanova V, Hu M, Nastoupil LJ, Oluwole OO, Patel VG, Oliai C, Riedell PA, Bishop MR, Shah GL, Perales MA, Schachter L, Maziarz RT, McGuirk JP. Patient Characteristics and Outcomes of Outpatient Tisagenlecleucel Recipients for B Cell Non-Hodgkin Lymphoma. Transplant Cell Ther 2023; 29:449.e1-449.e7. [PMID: 37120134 PMCID: PMC11027185 DOI: 10.1016/j.jtct.2023.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/15/2023] [Accepted: 04/24/2023] [Indexed: 05/01/2023]
Abstract
Tisagenlecleucel (tisa-cel) is an approved CD19-directed chimeric antigen receptor T cell (CAR-T) therapy for relapsed/refractory B cell malignancies. Given potentially life-threatening toxicities, including cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome, inpatient tisa-cel infusion and toxicity monitoring are often considered; however, the toxicity profile of tisa-cel may be conducive to outpatient administration. Here we review the characteristics and outcomes of tisa-cel recipients treated in the outpatient setting. Patients age ≥18 years with B cell non-Hodgkin lymphoma who received tisa-cel between June 25, 2018, and January 22, 2021, at 9 US academic medical centers were included in a retrospective analysis. Six of the 9 representative centers (75%) had an outpatient program in place. A total of 157 patients were evaluable, including 93 (57%) in the outpatient treatment group and 64 (43%) in the inpatient treatment group. Baseline characteristics, toxicity and efficacy, and resource utilization were summarized. The most common lymphodepletion (LD) regimen was bendamustine in the outpatient group (65%) and fludarabine/cyclophosphamide (91%) in the inpatient group. The outpatient group had more patients with a Charlson Comorbidity Index of 0 (51% versus 15%; P < .001), fewer patients with an elevated lactate dehydrogenase (LDH) level above the normal range at the time of LD (32% versus 57%, P = .003) compared to the inpatient group, and a lower Endothelial Activation and Stress Index score (.57 versus 1.4; P < .001). Any-grade CRS and ICANS were lower in the outpatient group (29% versus 56% [P < .001] and 10% versus 16% [P = .051], respectively). Forty-two outpatient tisa-cel recipients (45%) required an unplanned admission, with a median length of stay of 5 days (range, 1 to 27 days), compared to 13 days (range, 4 to 38 days) in the inpatient group. The median number of tocilizumab doses administered was similar in the 2 groups as were the rate of intensive care unit (ICU) transfer (5% versus 8%; P = .5) and median length of ICU stay (6 days versus 5 days; P = .7). There were no toxicity-related deaths in the 30 days post-CAR-T infusion in either group. Progression-free survival and overall survival were similar in the 2 groups. With careful patient selection, outpatient tisa-cel administration is feasible and associated with similar efficacy outcomes as inpatient treatment. Outpatient toxicity monitoring and management may help optimize healthcare resource utilization.
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Affiliation(s)
- Nausheen Ahmed
- University of Kansas Medical Center, Kansas City, Kansas.
| | - William Wesson
- University of Kansas Medical Center, Kansas City, Kansas
| | | | - David L Porter
- University of Pennsylvania and Abramson Cancer Center, Philadelphia, Pennsylvania
| | - Sunita D Nasta
- University of Pennsylvania and Abramson Cancer Center, Philadelphia, Pennsylvania
| | - Jamie Brower
- University of Pennsylvania and Abramson Cancer Center, Philadelphia, Pennsylvania
| | - Veronika Bachanova
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Marie Hu
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Loretta J Nastoupil
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Olalekan O Oluwole
- Hematology Oncology and Stem Cell Transplant, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Vivek G Patel
- Hematology Oncology and Stem Cell Transplant, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Caspian Oliai
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Peter A Riedell
- The David and Etta Jonas Center for Cellular Therapy, University of Chicago, Chicago, Illinois
| | - Michael R Bishop
- The David and Etta Jonas Center for Cellular Therapy, University of Chicago, Chicago, Illinois
| | - Gunjan L Shah
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Miguel-Angel Perales
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Levanto Schachter
- Adult Blood and Marrow Stem Cell Transplant Program, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Richard T Maziarz
- Adult Blood and Marrow Stem Cell Transplant Program, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
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7
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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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8
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Vijenthira A, Kuruvilla J, Crump M, Jain M, Prica A. Cost-Effectiveness Analysis of Frontline Polatuzumab-Rituximab, Cyclophosphamide, Doxorubicin, and Prednisone and/or Second-Line Chimeric Antigen Receptor T-Cell Therapy Versus Standard of Care for Treatment of Patients With Intermediate- to High-Risk Diffuse Large B-Cell Lymphoma. J Clin Oncol 2023; 41:1577-1589. [PMID: 36315922 DOI: 10.1200/jco.22.00478] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Recent studies of polatuzumab vedotin and CD19 chimeric antigen receptor T-cell therapy (CAR-T) have shown significant improvements in progression-free survival over standard of care (SOC) for patients with diffuse large B-cell lymphoma. However, they are costly, and it is unclear whether these strategies, alone or combined, are cost-effective over SOC. METHODS A Markov model was constructed to compare four strategies for patients with newly diagnosed intermediate- to high-risk diffuse large B-cell lymphoma: strategy 1: polatuzumab-rituximab, cyclophosphamide, doxorubicin, and prednisone (R-CHP) plus second-line CAR-T for early relapse (< 12 months); strategy 2: polatuzumab-R-CHP plus second-line salvage therapy ± autologous stem-cell transplant; strategy 3: rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone plus second-line CAR-T for early relapse; strategy 4: SOC (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone plus second-line salvage therapy ± autologous stem-cell transplant). Transition probabilities were estimated from trial data. Lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated from US and Canadian payer perspectives. Willingness-to-pay (WTP) thresholds of $150,000 US dollars (USD) or Canadian dollars (CAD)/QALY were used. RESULTS In probabilistic analyses (10,000 simulations), each strategy was incrementally more effective than the previous strategy, but also more costly. Adding polatuzumab-R-CHP to the SOC had an ICER of $546,956 (338,797-1,199,923) USD/QALY and $245,381 (151,671-573,250) CAD/QALY. Adding second-line CAR-T to the SOC had an ICER of $309,813 (190,197-694,200) USD/QALY and $303,163 (221,300-1,063,864) CAD/QALY. Simultaneously adding both polatuzumab-R-CHP and second-line CAR-T to the SOC had an ICER of $488,284 (326,765-840,157) USD/QALY and $267,050 (182,832-520,922) CAD/QALY. CONCLUSION Given uncertain incremental benefits in long-term survival and high costs, neither polatuzumab-R-CHP frontline, CAR-T second-line, nor a combination are likely to be cost-effective in the United States or Canada at current pricing compared with the SOC.
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Affiliation(s)
- Abi Vijenthira
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - John Kuruvilla
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Michael Crump
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Michael Jain
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
| | - Anca Prica
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
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9
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Badaracco J, Gitlin M, Keating SJ. A Model to Estimate Cytokine Release Syndrome and Neurological Event Management Costs Associated With CAR T-Cell Therapy. Transplant Cell Ther 2023; 29:59.e1-59.e6. [PMID: 36272529 DOI: 10.1016/j.jtct.2022.10.009] [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: 06/14/2022] [Revised: 09/27/2022] [Accepted: 10/13/2022] [Indexed: 11/15/2022]
Abstract
Chimeric antigen receptor (CAR) T-cell therapies demonstrated efficacy in relapsed/refractory large B-cell lymphoma (LBCL) but are associated with cytokine release syndrome (CRS) and neurological events (NE). We wanted to estimate the total cost of CRS and NE management among patients with relapsed/refractory LBCL treated with lisocabtagene maraleucel (liso-cel), axicabtagene ciloleucel (axi-cel), or tisagenlecleucel (tisa-cel) in the third- or later-line setting. An economic decision tree model was developed using clinical and economic data to estimate a weighted average per-patient adverse event (AE) management cost from a United States health care system perspective in 2020 dollars. In 2 predefined analyses, mean expected cost and 95% confidence intervals of the average treated patient were estimated via Monte Carlo simulations, with per-patient costs for each CAR T-cell therapy further stratified by AE and grade. In the base case, the overall weighted average per-patient cost was $18,718, $47,665, and $42,538 for liso-cel, axi-cel, and tisa-cel, respectively. The weighted average per-patient cost per CRS event was $8213, $20,442, and $26,009 for liso-cel, axi-cel, and tisa-cel, respectively; the weighted average per-patient cost per NE was $10,505, $27,223, and $16,528, respectively. Differences in the base-case scenario estimated total mean costs for liso-cel were -$28,947 and -$23,819 compared with axi-cel and tisa-cel, respectively. In the scenario analysis (alternative cost input), differences in the estimated total mean costs were -$24,498 for liso-cel versus axi-cel, and -$19,326 for liso-cel versus tisa-cel. Across the base case and scenario analysis, liso-cel had the lowest weighted average CRS and NE costs per treated patient compared with axi-cel and tisa-cel owing to lower incidence rates and symptom severity. These findings highlight the economic implications of differences in safety among CAR T-cell therapies.
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Cummings Joyner AK, Snider JT, Wade SW, Wang ST, Buessing MG, Johnson S, Gergis U. Cost-Effectiveness of Chimeric Antigen Receptor T Cell Therapy in Patients with Relapsed or Refractory Large B Cell Lymphoma: No Impact of Site of Care. Adv Ther 2022; 39:3560-3577. [PMID: 35689726 PMCID: PMC9309131 DOI: 10.1007/s12325-022-02188-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/10/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Cost-effectiveness data on chimeric antigen receptor (CAR) T cell therapies for relapsed/refractory large B cell lymphoma (R/R LBCL), accounting for inpatient/outpatient site of care (site), are sparse. METHODS This payer model compares lifetime costs/benefits for CAR T cell-treated (axicabtagene ciloleucel [axi-cel], lisocabtagene maraleucel [liso-cel], tisagenlecleucel [tisa-cel]) patients with R/R LBCL in the USA. Three-month post-infusion costs were derived from unit costs and real-world all-payer (RW) site-specific utilization data for 1175 patients with diffuse R/R LBCL (CAR T cell therapy October 2017-September 2020). Therapy- and site-specific grade 3+ cytokine release syndrome (CRS) and neurologic event (NE) incidences were imputed from published trials. Lifetime quality-adjusted life-years (QALYs) and long-term costs were calculated from therapy-specific overall and progression-free survival data, adjusted for differences in trial populations. The base case used 17% outpatient site (RW) for all therapies. ZUMA-1 trial cohorts 1/2 informed other axi-cel base case inputs; ZUMA-1 cohorts 4/6 data (updated safety management) supported scenario analyses. RESULTS Base case total costs for axi-cel exceeded liso-cel ($637 K versus $621 K) and tisa-cel ($631 K versus $577 K) costs. Three-month post-infusion costs were $57 K to $59 K across all therapies. Total QALYs for axi-cel also exceeded those for liso-cel (7.7 versus 5.9) and tisa-cel (7.2 versus 5.0) with incremental costs per QALY gained of $9 K versus liso-cel and $25 K versus tisa-cel. Base case incremental net monetary benefit was $255 K (95% confidence interval (CI) $181-326 K) for axi-cel versus liso-cel, and $280 K (95% CI $200-353 K) versus tisa-cel. Longer survival with axi-cel conferred higher lifetime costs. In all scenarios (e.g., varied outpatient proportions, CRS/NE incidence), axi-cel was cost-effective versus both comparators at a maximum willingness-to-pay of under $26 K/QALY as a result of axi-cel's higher incremental survival gains and quality-of-life. CONCLUSIONS Axi-cel is a cost-effective CAR T cell therapy for patients with R/R LBCL compared to tisa-cel and liso-cel. Site of care does not impact the cost-effectiveness of CAR T cell therapy.
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Affiliation(s)
| | | | - Sally West Wade
- Wade Outcomes Research and Consulting, 136 U Street, Salt Lake City, UT 84103 USA
| | - Si-Tien Wang
- Medicus Economics, LLC, 2 Stonehill Lane, Milton, MA 02186 USA
| | | | - Scott Johnson
- Medicus Economics, LLC, 2 Stonehill Lane, Milton, MA 02186 USA
| | - Usama Gergis
- Thomas Jefferson University Hospital, 925 Chestnut Street, Suite 420A, Philadelphia, PA 19107 USA
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11
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Pettinati MJ, Lajevardi-Khosh A, Rajput KS, Majmudar M, Selvaraj N. Towards Remote Continuous Monitoring of Cytokine Release Syndrome. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:966-970. [PMID: 36086220 DOI: 10.1109/embc48229.2022.9871716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Cytokine release syndrome (CRS) is a noninfec-tious systemic inflammatory response syndrome condition and a principle severe adverse event common in oncology patients treated with immunotherapies. Accurate monitoring and timely prediction of CRS severity remain a challenge. This study presents an XGBoost-based machine learning algorithm for forecasting CRS severity (no CRS, mild- and severe-CRS classes) in the 24 hours following the time of prediction utilizing the common vital signs and Glasgow coma scale (GCS) questionnaire inputs. The CRS algorithm was developed and evaluated on a cohort of patients (n=1,139) surgically treated for neoplasm with no ICD9 codes for infection or sepsis during a collective 9,892 patient-days of monitoring in ICU settings. Different models were trained with unique feature sets to mimic practical monitoring environments where different types of data availability will exist. The CRS models that incorporated all time series features up to the prediction time showcased a micro-average area under curve (AUC) statistic for the receiver operating characteristic curve (ROC) of 0.94 for the 3 classes of CRS grades. Models developed on a second cohort requiring data within the 24 hours preceding prediction time showcased a relatively lower 0.88 micro-average AUROC as these models did not benefit from implicit information in the data availability. Systematic removal of blood pressure and/or GCS inputs revealed significant decreases (p<0.05) in model performances that confirm the importance of such features for CRS prediction. Accurate CRS prediction and timely intervention can reverse CRS adverse events and maximize the benefit of immunotherapies in oncology patients.
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12
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Kamal-Bahl S, Puckett JT, Bagchi I, Miller-Sonet E, Huntington SF. Barriers and solutions to improve access for chimeric antigen receptor therapies. Immunotherapy 2022; 14:741-753. [PMID: 35621253 DOI: 10.2217/imt-2022-0037] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Chimeric antigen receptor T cells are a potentially curative new therapeutic option, but access challenges remain. The limited number of certified treatment centers and the need to travel to these centers, the expenses of travel and lodging and the out-of-pocket costs associated with treatment pose a challenge for patients. Further, the logistics of follow-up coupled with an ad hoc reimbursement environment make chimeric antigen receptor T-cell treatment an unattractive proposition for many providers. The patient-specific nature of these gene therapies has made scaling up production difficult for manufacturers. Providing expanded financial assistance for patients and education for community oncologists, and addressing reimbursement challenges, can alleviate some of these access barriers.
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Affiliation(s)
| | | | | | | | - Scott F Huntington
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT 06510, USA
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13
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Jia Q, Wang A, Yuan Y, Zhu B, Long H. Heterogeneity of the tumor immune microenvironment and its clinical relevance. Exp Hematol Oncol 2022; 11:24. [PMID: 35461288 PMCID: PMC9034473 DOI: 10.1186/s40164-022-00277-y] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/10/2022] [Indexed: 02/08/2023] Open
Abstract
During the course of tumorigenesis and subsequent metastasis, malignant cells gradually diversify and become more heterogeneous. Consequently, the tumor mass might be infiltrated by diverse immune-related components, including the cytokine/chemokine environment, cytotoxic activity, or immunosuppressive elements. This immunological heterogeneity is universally presented spatially or varies temporally along with tumor evolution or therapeutic intervention across almost all solid tumors. The heterogeneity of anti-tumor immunity shows a profound association with the progression of disease and responsiveness to treatment, particularly in the realm of immunotherapy. Therefore, an accurate understanding of tumor immunological heterogeneity is essential for the development of effective therapies. Facilitated by multi-regional and -omics sequencing, single cell sequencing, and longitudinal liquid biopsy approaches, recent studies have demonstrated the potential to investigate the complexity of immunological heterogeneity of the tumors and its clinical relevance in immunotherapy. Here, we aimed to review the mechanism underlying the heterogeneity of the immune microenvironment. We also explored how clinical assessments of tumor heterogeneity might facilitate the development of more effective personalized therapies.
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Affiliation(s)
- Qingzhu Jia
- Institute of Cancer, Xinqiao Hospital, Army Military Medical University, Xinqiao Main Street, Chongqing, 400037, China.,Chongqing Key Laboratory of Immunotherapy, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Aoyun Wang
- Institute of Cancer, Xinqiao Hospital, Army Military Medical University, Xinqiao Main Street, Chongqing, 400037, China.,Chongqing Key Laboratory of Immunotherapy, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Yixiao Yuan
- Department of Thoracic Surgery, The Third Affiliated Hospital of Kunming Medical University, Kunming, 650118, China
| | - Bo Zhu
- Institute of Cancer, Xinqiao Hospital, Army Military Medical University, Xinqiao Main Street, Chongqing, 400037, China. .,Chongqing Key Laboratory of Immunotherapy, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China.
| | - Haixia Long
- Institute of Cancer, Xinqiao Hospital, Army Military Medical University, Xinqiao Main Street, Chongqing, 400037, China. .,Chongqing Key Laboratory of Immunotherapy, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China.
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14
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Health Care Resource Utilization and Total Costs of Care Among Patients With Diffuse Large B-Cell Lymphoma Treated With Chimeric Antigen Receptor T-Cell Therapies in the United States. Transplant Cell Ther 2022; 28:404.e1-404.e6. [PMID: 35354101 DOI: 10.1016/j.jtct.2022.03.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/09/2022] [Accepted: 03/23/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Use of chimeric antigen receptor (CAR) T-cell therapy after second relapse of diffuse large B-cell lymphoma (DLBCL) has shown favorable efficacy in clinical trials. Yet, little is known about health care resource utilization (HCRU) and costs of CAR T-cell therapy among patients treated in real world settings. OBJECTIVES We assessed treatment patterns, HCRU, costs, and safety in patients receiving CAR T-cell therapy for relapsed or refractory DLBCL across 3 United States (US) commercial claims databases. STUDY DESIGN Adults with DLBCL treated with CAR T-cell therapies were identified in the following 3 claims databases: Optum® Clinformatics® Data Mart, IBM MarketScan® Commercial & Medicare Database, and IQVIA PharMetrics® Plus. Mean total costs were calculated and adjusted to 2019 US dollars. HCRU and costs within 3 months of infusion were stratified by safety events of interest, including neurological events (NE) and cytokine release syndrome (CRS), identified via unvalidated algorithms designed from expert medical opinion. RESULTS A total of 191 patients receiving CAR T-cell therapy were identified across databases; mean age ranged from 55 to 63 years and ≥63% of patients were male. Most patients (≥88%) received CAR T-cell infusions in the inpatient setting; 30%‒75% received bridging therapy. CRS was reported in 75%‒84% of patients (severe CRS, 15%‒32%); NEs were reported in 58%‒69% (severe NEs, 25%‒43%). Mean total inpatient hospital days ranged from 17 to 22 days and increased with severe CRS (19‒27 days) or severe NEs (22‒29 days). Mean total health care expenditures ranged from $380,000 to $526,000 and were generally higher with severe CRS or NEs (∼$406,000‒$679,000; Figure). CONCLUSIONS HCRU and costs associated with CAR T-cell therapy may vary in the real world depending on several factors, including occurrence and severity of adverse events.
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15
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Shimabukuro-Vornhagen A, Böll B, Schellongowski P, Valade S, Metaxa V, Azoulay E, von Bergwelt-Baildon M. Critical care management of chimeric antigen receptor T-cell therapy recipients. CA Cancer J Clin 2022; 72:78-93. [PMID: 34613616 DOI: 10.3322/caac.21702] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/30/2021] [Accepted: 07/21/2021] [Indexed: 12/30/2022] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy is a promising immunotherapeutic treatment concept that is changing the treatment approach to hematologic malignancies. The development of CAR T-cell therapy represents a prime example for the successful bench-to-bedside translation of advances in immunology and cellular therapy into clinical practice. The currently available CAR T-cell products have shown high response rates and long-term remissions in patients with relapsed/refractory acute lymphoblastic leukemia and relapsed/refractory lymphoma. However, CAR T-cell therapy can induce severe life-threatening toxicities such as cytokine release syndrome, neurotoxicity, or infection, which require rapid and aggressive medical treatment in the intensive care unit setting. In this review, the authors provide an overview of the state-of-the-art in the clinical management of severe life-threatening events in CAR T-cell recipients. Furthermore, key challenges that have to be overcome to maximize the safety of CAR T cells are discussed.
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Affiliation(s)
- Alexander Shimabukuro-Vornhagen
- Department I of Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
| | - Boris Böll
- Department I of Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
| | - Peter Schellongowski
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
- Department of Medicine I, Intensive Care Unit 13i2, Comprehensive Cancer Center, Center of Excellence in Medical Intensive Care (CEMIC), Medical University of Vienna, Vienna, Austria
| | - Sandrine Valade
- Medical Intensive Care Unit, St Louis Teaching Hospital, Public Assistance Hospitals of Paris, Paris, France
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Elie Azoulay
- Medical Intensive Care Unit, St Louis Teaching Hospital, Public Assistance Hospitals of Paris, Paris, France
| | - Michael von Bergwelt-Baildon
- Intensive Care in Hematologic and Oncologic Patients (iCHOP), Cologne, Germany
- Department of Medicine III, University Hospital, Ludwig-Maximilians University Munich, Munich, Germany
- Munich Comprehensive Cancer Center, University Hospital, Ludwig-Maximilians University Munich, Munich, Germany
- Bavarian Center for Cancer Research, Munich, Germany
- Nine-i Multinational Research Network, Service de Médecine Intensive et Réanimaton Médicale, Hôpital Saint-Louis, France
- German Cancer Consortium, Partner Site Munich, Munich, Germany
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16
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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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17
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Mehta PH, Fiorenza S, Koldej RM, Jaworowski A, Ritchie DS, Quinn KM. T Cell Fitness and Autologous CAR T Cell Therapy in Haematologic Malignancy. Front Immunol 2021; 12:780442. [PMID: 34899742 PMCID: PMC8658247 DOI: 10.3389/fimmu.2021.780442] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/05/2021] [Indexed: 12/14/2022] Open
Abstract
A range of emerging therapeutic approaches for the treatment of cancer aim to induce or augment endogenous T cell responses. Chimeric antigen receptor (CAR) T cell therapy (CTT) is one such approach that utilises the patient’s own T cells, engineered ex vivo to target cell surface antigens, to eliminate haematological malignancies. Despite mediating high rates of responses in some clinical trials, this approach can be limited by dysfunctional T cells if they are present at high frequencies either in the starting material from the patient or the CAR T cell product. The fitness of an individual’s T cells, driven by age, chronic infection, disease burden and cancer treatment, is therefore likely to be a crucial limiting factor of CTT. Currently, T cell dysfunction and its impact on CTT is not specifically quantified when patients are considering the therapy. Here, we review our current understanding of T cell fitness for CTT, how fitness may be impacted by age, chronic infection, malignancy, and treatment. Finally, we explore options to specifically tailor clinical decision-making and the CTT protocol for patients with more extensive dysfunction to improve treatment efficacy. A greater understanding of T cell fitness throughout a patient’s treatment course could ultimately be used to identify patients likely to achieve favourable CTT outcomes and improve methods for T cell collection and CTT delivery.
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Affiliation(s)
- Palak H Mehta
- School of Health and Biomedical Sciences, Royal Melbourne Institute of Technology (RMIT) University, Bundoora, VIC, Australia
| | - Salvatore Fiorenza
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Rachel M Koldej
- Australian Cancer Research Foundation (ACRF) Translational Laboratory, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Anthony Jaworowski
- School of Health and Biomedical Sciences, Royal Melbourne Institute of Technology (RMIT) University, Bundoora, VIC, Australia
| | - David S Ritchie
- Australian Cancer Research Foundation (ACRF) Translational Laboratory, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Kylie M Quinn
- School of Health and Biomedical Sciences, Royal Melbourne Institute of Technology (RMIT) University, Bundoora, VIC, Australia.,Department of Biochemistry, Biomedicine Discovery Institute, Monash University, Clayton, VIC, Australia
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18
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Karmali R. Relapsed disease: off-the-shelf immunotherapies vs customized engineered products. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:164-173. [PMID: 34889415 PMCID: PMC8791138 DOI: 10.1182/hematology.2021000249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Innovations in immuno-oncology for lymphomas have outpaced therapeutic developments in any other cancer histology. In the 1990s, rituximab, a CD20 monoclonal antibody, drastically changed treatment paradigms for B-cell non-Hodgkin lymphomas (B-NHLs). In parallel, the concept that T cells could be genetically reprogrammed and regulated to address tumor cell evasion was developed. Twenty years later, this concept has materialized-3 customized engineered CD19 chimeric antigen receptor T-cell (CART) constructs have been embraced as third-line therapies and beyond for aggressive B-NHL. Responses with CARTs are durable in 30% to 40% of patients, with consistent results in older patients, primary refractory disease, high-grade B-cell lymphoma, and patients with concurrent secondary central nervous system disease, all features historically associated with poorer outcomes. Challenges associated with the administration of CARTs include cumbersome and time-consuming manufacturing processes, toxicities, and cost, not to mention a substantial risk of relapse. Fortunately, as our understanding of how to manipulate the immune system to achieve full antitumor potential has grown, so has the rapid development of off-the-shelf immunotherapies, with CD20/CD3 bispecific antibodies standing out above all others. These agents have shown promising activity in aggressive B-NHL and have the potential to circumvent some of the challenges encountered with customized engineered products. However, toxicities remain substantial, dosing schedules intensive, and experience limited with these agents. Novel customized and off-the-shelf therapeutics as well as rational combinations of these agents are underway. Ultimately, growing experience with both customized engineered and off-the-shelf immunotherapies will provide guidance on optimal methods of delivery and sequencing.
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Affiliation(s)
- Reem Karmali
- Correspondence Reem Karmali, Northwestern University Feinberg School of Medicine, 676 N St Clair St, Ste 850, Chicago, IL 60611; e-mail:
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19
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Maloney DG, Kuruvilla J, Liu FF, Kostic A, Kim Y, Bonner A, Zhang Y, Fox CP, Cartron G. Matching-adjusted indirect treatment comparison of liso-cel versus axi-cel in relapsed or refractory large B cell lymphoma. J Hematol Oncol 2021; 14:140. [PMID: 34493319 PMCID: PMC8425084 DOI: 10.1186/s13045-021-01144-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/21/2021] [Indexed: 01/17/2023] Open
Abstract
Background In the absence of randomized studies directly comparing chimeric antigen receptor T cell therapies, this study used matching-adjusted indirect comparisons (MAIC) to evaluate the comparative efficacy and safety of lisocabtagene maraleucel (liso-cel) versus axicabtagene ciloleucel (axi-cel) in patients with relapsed or refractory large B cell lymphoma (LBCL). Methods Primary data sources included individual patient data from the TRANSCEND NHL 001 study (TRANSCEND [NCT02631044]; N = 256 for efficacy set, N = 269 for safety set) for liso-cel and summary-level data from the ZUMA-1 study (NCT02348216; N = 101 for efficacy set, N = 108 for safety set) for axi-cel. Inter-study differences in design, eligibility criteria, baseline characteristics, and outcomes were assessed and aligned to the extent feasible. Clinically relevant prognostic factors were adjusted in a stepwise fashion by ranked order. Since bridging therapy was allowed in TRANSCEND but not ZUMA-1, the initial efficacy and safety analyses included bridging therapy use as a matching factor (TRANSCEND patients who received bridging therapy were removed). Subsequent sensitivity analyses excluded this matching factor. Results The initial analysis showed similar MAIC-weighted efficacy outcomes between TRANSCEND and ZUMA-1 for overall and complete response rates (odds ratio [95% confidence interval (CI)], 1.40 [0.56–3.49] and 1.21 [0.56–2.64], respectively) and for overall survival and progression-free survival (hazard ratio [95% CI], 0.81 [0.44–1.49] and 0.95 [0.58–1.57], respectively). MAIC-weighted safety outcomes favored liso-cel, with significantly lower odds of all-grade and grade ≥ 3 cytokine release syndrome (odds ratio [95% CI], 0.03 [0.01–0.07] and 0.08 [0.01–0.67], respectively) and study-specific neurological events (0.16 [0.08–0.33] and 0.05 [0.02–0.15], respectively). Efficacy and safety outcomes remained similar in sensitivity analyses, which did not include use of bridging therapy as a matching factor. Conclusions After matching and adjusting for clinically relevant prognostic factors, liso-cel demonstrated comparable efficacy and a more favorable safety profile compared with axi-cel in patients with third- or later-line relapsed or refractory LBCL. Trial registration: NCT02631044 and NCT02348216 Supplementary Information The online version contains supplementary material available at 10.1186/s13045-021-01144-9.
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Affiliation(s)
- David G Maloney
- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA, 98109-1024, USA.
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