1
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Sureda A, Adam SE, Yang S, Griffin E, Baker J, Johnston K, Navarro FR, Alhasani S, Chhibber A, Wang A, Mutebi A. Logistical challenges of CAR T-cell therapy in non-Hodgkin lymphoma: a survey of healthcare professionals. Future Oncol 2024:1-14. [PMID: 39268892 DOI: 10.1080/14796694.2024.2393566] [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: 06/26/2024] [Accepted: 08/14/2024] [Indexed: 09/15/2024] Open
Abstract
Aim: Characterize the logistical challenges faced by healthcare professionals (HCPs), patients and caregivers during the chimeric antigen receptor T-cell (CAR T) treatment process for non-Hodgkin lymphoma patients.Materials & methods: HCPs in the US and UK experienced with CAR T administration participated in interviews and completed a web-based survey.Results: A total of 133 (80 US, 53 UK) HCPs participated. Two or more logistical challenges were identified by ≥60% of respondents across all stages of the CAR T process. Commonly reported challenges were lengthy waiting periods, administrative and payer-related barriers, limited healthcare capacity, caregiver support and (particularly in the US) patient out-of-pocket costs.Conclusion: The CAR T treatment process presents numerous challenges, highlighting an unmet need for more convenient therapies.
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Affiliation(s)
- Anna Sureda
- Institut Català d'Oncologia, Hospital Duran i Reynals, IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
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2
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Dandoy CE, Adams J, Artz A, Bredeson C, Dahi PB, Dodd T, Jaglowski S, Lehmann L, LeMaistre CF, Mian A, Neal A, Page K, Rizzo JD, Rotz S, Sorror M, Steinberg A, Viswabandya A, Howard DS. In Pursuit of Optimal Outcomes: A Framework for Quality Standards in Immune Effector Cell Therapy. Transplant Cell Ther 2024:S2666-6367(24)00535-9. [PMID: 39067790 DOI: 10.1016/j.jtct.2024.07.011] [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: 05/18/2024] [Revised: 07/08/2024] [Accepted: 07/10/2024] [Indexed: 07/30/2024]
Abstract
Immune effector cell (IEC) therapy represents a transformative advancement in oncology, leveraging the immune system to combat various malignancies. This article outlines a comprehensive framework for establishing and maintaining quality standards in IEC therapy amidst rapid scientific and clinical advancements. We emphasize the integration of structured process measures, robust quality assurance, and meticulous outcome evaluation to ensure treatment efficacy and safety. Key components include multidisciplinary expertise, stringent accreditation protocols, and advanced data management systems, which facilitate standardized reporting and continual innovation. The collaborative effort among stakeholders-ranging from patients and healthcare providers to regulatory bodies-is crucial in delivering high-quality IEC therapies. This framework aims to enhance patient outcomes and cement the role of IEC therapy as a cornerstone of modern oncology, promoting continuous improvement and adherence to high standards across the therapeutic spectrum.
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Affiliation(s)
- Christopher E Dandoy
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, Ohio.
| | - Joan Adams
- Stephenson Cancer Center, OU Health Science Center The University of Oklahoma, Oklahoma City, Oklahoma
| | - Andrew Artz
- Division of Leukemia, Department of Hematology and HCT, City of Hope, Duarte, California
| | - Christopher Bredeson
- Ottawa Hospital Research Institute, Division of Hematology, University of Ottawa, Ottawa, Canada
| | - Parastoo B Dahi
- Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Therese Dodd
- Sarah Cannon Transplant and Cellular Therapy Network, Nashville, Tennessee
| | - Samantha Jaglowski
- Department of Pediatrics and Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Leslie Lehmann
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Amir Mian
- Department of Pediatric Hematology and Oncology, Department of Pediatrics at Dell Medical School, The University of Texas at Austin, Austin, Texas
| | - Alison Neal
- Department of Bone Marrow Transplant and Cellular Therapy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kristen Page
- Department of Pediatrics and Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - J Douglas Rizzo
- Department of Pediatrics and Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Seth Rotz
- Division of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, Ohio
| | - Mohamed Sorror
- Fred Hutchinson Cancer Center and University of Washington, Seattle, Washington
| | - Amir Steinberg
- Adult Stem Cell Transplantation, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Auro Viswabandya
- Department of Haematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Dianna S Howard
- Department of Internal Medicine, Section of Hematology and Oncology, Stem Cell Transplant and Cellular Therapy Program, Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston Salem, North Carolina
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3
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Bishop MR, Kay GE. CAR T-cell therapy: A collaboration between authorized treatment centers and community oncologists. Semin Oncol 2024; 51:87-94. [PMID: 38531760 DOI: 10.1053/j.seminoncol.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 01/31/2024] [Accepted: 02/02/2024] [Indexed: 03/28/2024]
Abstract
With the approval of the first CAR T-cell products for hematological malignancies in 2017, these autologous cell therapies have changed the treatment paradigm for patients with relapsed or refractory (r/r) non-Hodgkin lymphoma (NHL), who have a poor prognosis and few effective treatment options. Despite the demonstrated clinical benefit in patients with r/r diffuse large B-cell lymphoma, mantle cell lymphoma, and follicular lymphoma, many patients who are eligible for CAR T-cell therapies do not receive them or are treated with CAR T cells as a later line of therapy at advanced stages of disease. Several barriers exist for referring patients to an authorized treatment center (ATC) for CAR T-cell therapy. Although most patients with NHL are treated by community-based oncologists, educational gaps may exist for some community oncologists about the availability of CAR T-cell therapies in certain indications, the overall treatment process, and how they can access these therapies for their patients. In addition to navigation of the referral process from the community setting to the ATC, other barriers include timely identification of candidates eligible for CAR T-cell therapy and logistical and reimbursement concerns. Here, we examine the patient CAR T-cell experience, which begins and ends in the community setting, and identify and discuss opportunities for improved collaboration between community oncologists and ATC physicians to help address barriers to treatment and enhance patient outcomes. Treatment decisions for a patient's second or third line of therapy for NHL are critically important, owing to declining probabilities for favorable outcomes with each successive line of therapy. For patients who are eligible, CAR T-cell therapies should be considered as early as possible in their treatment course. A better understanding of the CAR T-cell process, the patient's experience, and the collaboration necessary for timely patient identification, better access, and successful outcomes will enable more patients to benefit from CAR T-cell therapies.
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Affiliation(s)
- Michael R Bishop
- The David and Etta Jonas Center for Cellular Therapy, University of Chicago, Chicago, IL.
| | - Gary E Kay
- Northwest Oncology and Hematology, Rolling Meadows, IL
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4
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Odstrcil MS, Lee CJ, Sobieski C, Weisdorf D, Couriel D. Access to CAR T-cell therapy: Focus on diversity, equity and inclusion. Blood Rev 2024; 63:101136. [PMID: 37863793 DOI: 10.1016/j.blre.2023.101136] [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: 08/07/2023] [Revised: 09/29/2023] [Accepted: 10/03/2023] [Indexed: 10/22/2023]
Abstract
Chimeric antigen receptor T-cell (CAR T-cell) therapy has revolutionized the treatment of hematologic malignancies in patients with relapsed or refractory disease without other treatment options. However, only a very small proportion of patients with an indication for CAR T-cell can access the treatment. The imbalance between supply and demand is magnified in minority and vulnerable populations. Limited access is multifactorial and in part a result of factors directly related to the cellular product such as cost, complex logistics and manufacturing limitations. On the other hand, the impact of diversity, equity, and inclusion (DEI) and their social and structural context are also key to understanding access barriers in cellular therapy and health care in general. CAR T-cell therapy provides us with a new opportunity to better understand and prioritize this gap, a key step towards proactively and strategically addressing access. The aim of this review is to provide an analysis of the current state of access to CAR T therapy with a focus on the influence of DEI. We will cover aspects related to the cellular product and the inseparable context of social and structural determinants. Identifying and addressing barriers is necessary to ensure equitable access to this and all future novel therapies.
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Affiliation(s)
- Maria S Odstrcil
- Huntsman Cancer Institute, University of Utah, Division of Hematology and Hematologic Malignancies, Salt Lake City, UT, USA
| | - Catherine J Lee
- Huntsman Cancer Institute, University of Utah, Division of Hematology and Hematologic Malignancies, Salt Lake City, UT, USA; Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA
| | - Catherine Sobieski
- Huntsman Cancer Institute, University of Utah, Division of Hematology and Hematologic Malignancies, Salt Lake City, UT, USA
| | - Daniel Weisdorf
- University of Minnesota Medical School, Division of Hematology, Oncology and Transplantation, Minneapolis, MN, USA
| | - Daniel Couriel
- Huntsman Cancer Institute, University of Utah, Division of Hematology and Hematologic Malignancies, Salt Lake City, UT, USA.
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5
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Badr H, Rouce R, Scheurer ME, Lulla P, Mims M, Reddy P. Bringing CAR T cell therapy trials to underserved populations. Cancer Cell 2023; 41:2007-2010. [PMID: 37890490 PMCID: PMC11146682 DOI: 10.1016/j.ccell.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 09/30/2023] [Accepted: 10/02/2023] [Indexed: 10/29/2023]
Abstract
There is a critical need for equitable access to cell therapies in cancer treatment, particularly within public safety-net healthcare systems that serve minority and socioeconomically disadvantaged populations. We discuss how the Dan L Duncan Comprehensive Cancer Center at Baylor College of Medicine is piloting a cell therapy program aimed at addressing cancer care disparities and has the potential to serve as a national model for enhancing health equity in cancer care.
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Affiliation(s)
- Hoda Badr
- Dan L Duncan Comprehensive Cancer Center, Houston, TX, USA; Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Rayne Rouce
- Dan L Duncan Comprehensive Cancer Center, Houston, TX, USA; Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.
| | - Michael E Scheurer
- Dan L Duncan Comprehensive Cancer Center, Houston, TX, USA; Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Premal Lulla
- Dan L Duncan Comprehensive Cancer Center, Houston, TX, USA; Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Martha Mims
- Dan L Duncan Comprehensive Cancer Center, Houston, TX, USA; Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Pavan Reddy
- Dan L Duncan Comprehensive Cancer Center, Houston, TX, USA; Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
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6
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Hoffmann MS, Hunter BD, Cobb PW, Varela JC, Munoz J. Overcoming Barriers to Referral for Chimeric Antigen Receptor T-Cell Therapy in Patients With Relapsed/Refractory Diffuse Large B-Cell Lymphoma. Transplant Cell Ther 2023:S2666-6367(23)01234-4. [PMID: 37031747 DOI: 10.1016/j.jtct.2023.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/18/2023] [Accepted: 04/03/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Diffuse large B-cell lymphoma (DLBCL) is the most prevalent subtype of non-Hodgkin lymphoma. Although outcomes to frontline therapy are encouraging, patients who are refractory to or relapse after first-line therapy experience inferior outcomes. A significant proportion of patients treated with additional lines of cytotoxic chemotherapy ultimately succumb to their disease as established in the SCHOLAR-1 study. CHIMERIC ANTIGEN RECEPTOR (CAR)-T CELL THERAPY CAR-T cell therapy is a novel approach to cancer management that reprograms a patient's own T cells to better target and eliminate cancer cells. It was initially approved by the US Food and Drug Administration (FDA) for patients with relapsed/refractory (r/r) DLBCL in the third line of treatment. Based on recently published randomized data, CAR-T cell therapy (axicabtagene ciloleucel and lisocabtagene maraleucel) has also been approved in the second line of treatment for patients who are primary refractory or relapse within 12 months of initiation of first-line therapy. Despite the proven efficacy in treating r/r DLBCL with cluster of differentiation (CD)19-directed CAR-T cell therapy, several barriers exist that may prevent eligible patients from receiving treatment. KEY BARRIERS TO CAR-T CELL TREATMENT Barriers to treatment include cost of therapy, patient hesitancy, required travel to academic treatment centers, nonreferrals, lack of understanding of CAR-T cell therapy, lack of caregiver support, knowledge of resources available, and timely patient selection by referring oncologists. CONCLUSION In this review, an overview of the FDA-approved CD19-directed CAR-T cell therapies (tisagenlecleucel, axicabtagene ciloleucel, and lisocabtagene maraleucel) is provided from pivotal clinical trials and supporting real-world evidence from retrospective studies. In both clinical trials and real-world settings CAR-T cell therapy has been shown to be safe and efficacious for treating patients with r/r DLBCL. However, several barriers prevent eligible patients from accessing these therapies. Barriers to referrals for CAR-T cell therapy are presented with recommendations to improve collaboration between community oncologists and physicians from CAR-T cell therapy treatment centers and subsequent long-term care of patients in community treatment centers.
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Affiliation(s)
- Marc S Hoffmann
- University of Kansas Cancer Center, Division of Hematologic Malignancies and Cellular Therapeutics, Westwood, KS
| | - Bradley D Hunter
- Blood and Marrow Transplantation, LDS Hospital, Intermountain Healthcare, Salt Lake City, UT
| | | | - Juan C Varela
- Blood and Marrow Transplant Program, AdventHealth Hospital, Orlando, FL; Beth Israel Deaconess Medical Center, Dana Farber/Harvard Cancer Center, Boston, MA
| | - Javier Munoz
- Department of Hematology, Mayo Clinic, Phoenix, AZ.
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7
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Spanjaart AM, Pennings ER, Kos M, Mutsaers PG, Lugtenburg PJ, van Meerten T, van Doesum JA, Minnema MC, Jak M, van Dorp S, Vermaat JS, van der Poel MW, van Oijen MG, Kuipers MT, Nijhof IS, Kersten MJ. Development of a Core Set of Patient- and Caregiver-Reported Signs and Symptoms to Facilitate Early Recognition of Acute Chimeric Antigen Receptor T-Cell Therapy Toxicities. JCO Oncol Pract 2023; 19:e407-e416. [PMID: 36508702 PMCID: PMC10022884 DOI: 10.1200/op.22.00501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/29/2022] [Accepted: 09/30/2022] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Prompt recognition of acute chimeric antigen receptor T (CAR T)-cell-mediated toxicities is crucial because adequate and timely management can prevent or reverse potential life-threatening complications. In the outpatient setting, patients and informal caregivers have to recognize and report signs and symptoms marking these acute toxicities. This study provides a core set of patient- and caregiver-reported signs and symptoms (outcomes, P/CROs) and definitions of red flags warranting immediate action to include in a daily checklist for support at home, with the goal to make outpatient post-CAR T-cell care safer, optimize patient and caregiver support, and thereby facilitating an early discharge/hospital visit reduction strategy. METHODS We performed a systematic review of phase II/III trials of US Food and Drug Administration-approved CAR T-cell products and selected all common and severe adverse events that could be translated into a P/CRO for inclusion in a two-round modified Delphi procedure. Eleven CAR T-cell-dedicated hematologists from the Dutch CAR T-cell tumorboard representing all treating centers selected P/CROs for inclusion in the core set and defined red flags. The final core set was evaluated with patients and caregivers. RESULTS From nine clinical trials, 457 adverse events were identified of which 42 could be used as P/CRO. The final core set contains 28 items, including five signs for measurement via wearables and two signs for caregiver-performed assessments. CONCLUSION This study provides a core set of P/CROs that can serve as a framework for (eHealth) tools that aim to enable patients and caregivers to more effectively recognize and report signs and symptoms of acute toxicities after CAR T-cell therapy, which will enhance safe outpatient treatment monitoring.
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Affiliation(s)
- Anne M. Spanjaart
- Amsterdam UMC Location University of Amsterdam, Hematology, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- LYMMCARE, Amsterdam, the Netherlands
| | - Elise R.A. Pennings
- Amsterdam UMC Location University of Amsterdam, Hematology, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- LYMMCARE, Amsterdam, the Netherlands
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Milan Kos
- Amsterdam University Medical Centers, University of Amsterdam, Department of Oncology, Amsterdam, the Netherlands
| | - Pim G.N.J. Mutsaers
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Hematology, Rotterdam, the Netherlands
| | - Pieternella J. Lugtenburg
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Hematology, Rotterdam, the Netherlands
| | - Tom van Meerten
- University Medical Center Groningen, Department of Hematology, Groningen, the Netherlands
| | - Jaap A. van Doesum
- University Medical Center Groningen, Department of Hematology, Groningen, the Netherlands
| | - Monique C. Minnema
- University Medical Center Utrecht, Department of Hematology, Utrecht, the Netherlands
| | - Margot Jak
- University Medical Center Utrecht, Department of Hematology, Utrecht, the Netherlands
| | - Suzanne van Dorp
- Radboud University Medical Center, Department of Hematology, Nijmegen, the Netherlands
| | - Joost S.P. Vermaat
- Leiden University Medical Center, Department of Hematology, Leiden, the Netherlands
| | - Marjolein W.M. van der Poel
- Department of Internal Medicine, Division of Hematology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Martijn G.H. van Oijen
- Amsterdam University Medical Centers, University of Amsterdam, Department of Oncology, Amsterdam, the Netherlands
| | - Maria T. Kuipers
- Amsterdam UMC Location University of Amsterdam, Hematology, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- LYMMCARE, Amsterdam, the Netherlands
| | - Inger S. Nijhof
- Amsterdam UMC Location University of Amsterdam, Hematology, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- LYMMCARE, Amsterdam, the Netherlands
- St Antonius Ziekenhuis Nieuwegein, Hematology, Nieuwegein, the Netherlands
| | - Marie José Kersten
- Amsterdam UMC Location University of Amsterdam, Hematology, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- LYMMCARE, Amsterdam, the Netherlands
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8
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Gagelmann N, Sureda A, Montoto S, Murray J, Bolaños N, Kenyon M, Beksac M, Schönland S, Hayden P, Scheurer H, Morgan K, Garderet L, McLornan DP, Ruggeri A. Access to and affordability of CAR T-cell therapy in multiple myeloma: an EBMT position paper. Lancet Haematol 2022; 9:e786-e795. [PMID: 36174641 DOI: 10.1016/s2352-3026(22)00226-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/21/2022] [Accepted: 07/08/2022] [Indexed: 06/16/2023]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy is a promising immunotherapeutic approach in the treatment of multiple myeloma, and the recent approval of the first two CAR T-cell products could result in improved outcomes. However, it remains a complex and expensive technology, which poses challenges to health-care systems and society in general, especially in times of crises. This potentially accelerates pre-existing inequalities as access to CAR T-cell therapy varies, both between countries, depending on the level of economic development, and within countries, due to structural disparities in access to quality health care-a parameter strongly correlated with socioeconomic status, ethnicity, and lifestyle. Here, we identify two important issues: affordability and access to CAR T-cell treatment. This consensus statement from clinical investigators, clinicians, nurses, and patients from the European Society for Blood and Marrow Transplantation (EBMT) proposes solutions as part of an innovative collaborative strategy to make CAR T-cell therapy accessible to all patients with multiple myeloma.
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Affiliation(s)
- Nico Gagelmann
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Anna Sureda
- Institut Català d'Oncologia, Hospital Duran i Reynals, Barcelona, Spain
| | - Silvia Montoto
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - John Murray
- The Christie NHS Foundation Trust, Manchester, UK
| | | | - Michelle Kenyon
- Department of Haematology, King's College Hospital NHS Foundation Trust, London, UK
| | - Meral Beksac
- Department of Hematology, Ankara University, Ankara, Turkey
| | - Stefan Schönland
- Medical Department V, Heidelberg University Hospital, Heidelberg, Germany
| | - Patrick Hayden
- Department of Hematology, Trinity College Dublin, St James's Hospital, Dublin, Ireland
| | | | | | - Laurent Garderet
- Service d'Hématologie et Thérapie Cellulaire, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France
| | - Donal P McLornan
- Department of Haematology and Stem Cell Transplantation, University College Hospital, London, UK
| | - Annalisa Ruggeri
- Hematology and BMT Unit, San Raffaele Scientific Institute, Milano, Italy
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9
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Chen AJ, Zhang J, Agarwal A, Lakdawalla DN. Value of Reducing Wait Times for Chimeric Antigen Receptor T-Cell Treatment: Evidence From Randomized Controlled Trial Data on Tisagenlecleucel for Diffuse Large B-Cell Lymphoma. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:1344-1351. [PMID: 35341689 DOI: 10.1016/j.jval.2022.02.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/30/2022] [Accepted: 02/08/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES This study aimed to quantify the value of reducing chimeric antigen receptor T-cell (CAR-T) treatment wait times on patients with refractory and relapsed aggressive blood cancer who can newly gain access to treatment or access treatment earlier in their disease course. METHODS Using data from the JULIET clinical trial, we first identified the number of additional patients with diffuse large B-cell lymphoma that would have been treated with tisagenlecleucel CAR-T therapy if wait times were shortened. For these patients, we estimated mortality benefits using literature estimates of CAR-T effectiveness. Next, among patients who already received CAR-T, we estimated tumor burden progression over time using a linear probability regression model. The primary outcome variable was an indicator for having above-normal lactate dehydrogenase, and we controlled for time, use of bridging therapy, and time-invariant patient characteristics. The regression results, along with literature estimates relating lactate dehydrogenase to CAR-T effectiveness, were used to compute the survival benefits of earlier CAR-T treatment. RESULTS Reducing wait times by 2 months increased the number of eligible patients receiving CAR-T by at least 10.7%. For patients already receiving tisagenlecleucel CAR-T, a 2-month reduction in wait times generated a 3.3% increase in survival gains per treated patient. Thus, among patients seeking treatment, the combined treatment efficacy increased by 14%, with approximately one-quarter of survival benefits accruing to existing patients receiving faster treatment. CONCLUSIONS Delays affected not only access to CAR-T treatments but also treatment effectiveness. Our results highlight the survival benefits of expediting treatment access and may help explain some observed differences in CAR-T effectiveness across countries.
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Affiliation(s)
- Alice J Chen
- Sol Price School of Public Policy and Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA.
| | - Jie Zhang
- Novartis Pharmaceuticals, Basel, Switzerland
| | | | - Darius N Lakdawalla
- Sol Price School of Public Policy and Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
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10
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ABCs of ADCs in Management of Relapsed/refractory diffuse large B-cell lymphoma. Blood Rev 2022; 56:100967. [DOI: 10.1016/j.blre.2022.100967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 04/15/2022] [Accepted: 04/19/2022] [Indexed: 11/19/2022]
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11
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Banerjee R, Shah N, Dicker AP. Next-Generation Implementation of Chimeric Antigen Receptor T-Cell Therapy Using Digital Health. JCO Clin Cancer Inform 2021; 5:668-678. [PMID: 34110929 DOI: 10.1200/cci.21.00023] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Chimeric antigen receptor T-cell (CAR-T) therapy is a paradigm-shifting immunotherapy modality in oncology; however, unique toxicities such as cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome limit its ability to be implemented more widely in the outpatient setting or at smaller-volume centers. Three operational challenges with CAR-T therapy include the following: (1) the logistics of toxicity monitoring, ie, with frequent vital sign checks and neurologic assessments; (2) the specialized knowledge required for toxicity management, particularly with regard to CRS and immune effector cell-associated neurotoxicity syndrome; and (3) the need for high-quality symptomatic and supportive care during this intensive period. In this review, we explore potential niches for digital innovations that can improve the implementation of CAR-T therapy in each of these domains. These tools include patient-facing technologies and provider-facing platforms: for example, wearable devices and mobile health apps to screen for fevers and encephalopathy, electronic patient-reported outcome assessments-based workflows to assist with symptom management, machine learning algorithms to predict emerging CRS in real time, clinical decision support systems to assist with toxicity management, and digital coaching to help maintain wellness. Televisits, which have grown in prominence since the novel coronavirus pandemic, will continue to play a key role in the monitoring and management of CAR-T-related toxicities as well. Limitations of these strategies include the need to ensure care equity and stakeholder buy-in, both operationally and financially. Nevertheless, once developed and validated, the next-generation implementation of CAR-T therapy using these digital tools may improve both its safety and accessibility.
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Affiliation(s)
- Rahul Banerjee
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Nina Shah
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Adam P Dicker
- Department of Radiation Oncology, Jefferson University, Philadelphia, PA.,Jefferson Center for Digital Health, Jefferson University, Philadelphia, PA
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12
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Banerjee R, Fakhri B, Shah N. Toci or not toci: innovations in the diagnosis, prevention, and early management of cytokine release syndrome. Leuk Lymphoma 2021; 62:2600-2611. [PMID: 34151714 DOI: 10.1080/10428194.2021.1924370] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Cytokine release syndrome (CRS) remains a significant toxicity of chimeric antigen receptor T-cell (CAR-T) therapy for hematologic malignancies. While established guidelines exist for the management of Grade 2+ CRS with immunosuppressive agents such as tocilizumab or corticosteroids, the management of early-grade CRS (i.e. Grade 1 CRS with isolated fevers) has no such consensus beyond supportive care. In this review, we discuss early-grade CRS with an emphasis on its diagnosis, management, and prevention. Strategies to target early-grade CRS include immunosuppression preemptively (once CRS develops) or prophylactically (before CRS develops) as well as novel small-molecule inhibitors or fractionated CAR-T dosing. In the near future, next-generation CAR-T therapies may be able to target CRS precisely or obviate CRS entirely. If shown to prevent CRS-associated morbidity while maintaining therapeutic anti-neoplastic efficacy, these innovative strategies will enhance the safety of CAR-T therapy while also improving its operationalization and accessibility in the real-world setting.
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Affiliation(s)
- Rahul Banerjee
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Bita Fakhri
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Nina Shah
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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