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Eigendorff F, Filimonova I, Scholl S, Sayer-Klink A, Rummler S, Kunert C, Pietschmann K, Wittig A, Hochhaus A, Schnetzke U. Effective bridging strategies prior to infusion with tisagenlecleucel results in high response rates and long-term remission in relapsed/refractory large B-cell lymphoma: findings from a German monocentric study. J Cancer Res Clin Oncol 2024; 150:224. [PMID: 38693452 PMCID: PMC11062962 DOI: 10.1007/s00432-024-05765-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 04/23/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Incorporating chimeric antigen receptor (CAR)-T cell therapy into relapsed or refractory large B-cell lymphoma (rr LBCL) treatment algorithms has yielded remarkable response rates and durable remissions, yet a substantial portion of patients experience progression or relapse. Variations in outcomes across treatment centers may be attributed to different bridging strategies and remission statuses preceding CAR-T cell therapy. PATIENTS Twenty-nine consecutive adult patients receiving tisagenlecleucel (tisa-cel) for rr LBCL from December 2019 to February 2023 at Jena University Hospital were analyzed. RESULTS The median age was 63, with a median of 3 prior treatments. Twenty patients (69%) were refractory to any systemic therapy before CAR-T cell treatment. Following leukapheresis, 25 patients (86%) received bridging therapy with the majority undergoing chemotherapy (52%) or combined modality therapy (32%). Radiotherapy (RT) was part of the bridging strategy in 44%, with moderately hypofractionated involved site RT (30.0 Gy/2.5 Gy) being applied most frequently (64%). Post-CAR-T infusion, the objective response rate at 30 days was 83%, with 55% achieving complete response. Twelve-month progression-free (PFS) and overall survival (OS) were 60% and 74%, respectively, with a median follow up of 11.1 months for PFS and 17.9 months for OS. Factors significantly associated with PFS were chemotherapy sensitivity pre-leukapheresis and response to bridging. CONCLUSION The study underscores the importance of minimal tumor burden at CAR-T initiation, emphasizing the need for suitable bridging regimens. The findings advocate for clinical trials and further real-world analyses to optimize CAR-T cell therapy outcomes by identifying the most effective bridging strategies.
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MESH Headings
- Humans
- Male
- Middle Aged
- Female
- Aged
- Immunotherapy, Adoptive/methods
- Lymphoma, Large B-Cell, Diffuse/therapy
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/pathology
- Adult
- Remission Induction
- Neoplasm Recurrence, Local/therapy
- Neoplasm Recurrence, Local/pathology
- Germany
- Receptors, Antigen, T-Cell/therapeutic use
- Retrospective Studies
- Combined Modality Therapy
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Affiliation(s)
- Farina Eigendorff
- Klinik Für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
- Comprehensive Cancer Center Central Germany (CCCG) Jena/Leipzig, Campus Jena, Jena, Germany
| | - Irina Filimonova
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Jena, Jena, Germany
- Comprehensive Cancer Center Central Germany (CCCG) Jena/Leipzig, Campus Jena, Jena, Germany
| | - Sebastian Scholl
- Klinik Für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
- Comprehensive Cancer Center Central Germany (CCCG) Jena/Leipzig, Campus Jena, Jena, Germany
| | - Anne Sayer-Klink
- Institut für Transfusionsmedizin, Universitätsklinikum Jena, Jena, Germany
- Comprehensive Cancer Center Central Germany (CCCG) Jena/Leipzig, Campus Jena, Jena, Germany
| | - Silke Rummler
- Institut für Transfusionsmedizin, Universitätsklinikum Jena, Jena, Germany
- Comprehensive Cancer Center Central Germany (CCCG) Jena/Leipzig, Campus Jena, Jena, Germany
| | - Christa Kunert
- Klinik Für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
- Comprehensive Cancer Center Central Germany (CCCG) Jena/Leipzig, Campus Jena, Jena, Germany
| | - Klaus Pietschmann
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Jena, Jena, Germany
- Comprehensive Cancer Center Central Germany (CCCG) Jena/Leipzig, Campus Jena, Jena, Germany
| | - Andrea Wittig
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Jena, Jena, Germany
- Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Andreas Hochhaus
- Klinik Für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
- Comprehensive Cancer Center Central Germany (CCCG) Jena/Leipzig, Campus Jena, Jena, Germany
| | - Ulf Schnetzke
- Klinik Für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany.
- Comprehensive Cancer Center Central Germany (CCCG) Jena/Leipzig, Campus Jena, Jena, Germany.
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Kegyes D, Ghiaur G, Bancos A, Tomuleasa C, Gale RP. Immune therapies of B-cell acute lymphoblastic leukaemia in children and adults. Crit Rev Oncol Hematol 2024; 196:104317. [PMID: 38437908 DOI: 10.1016/j.critrevonc.2024.104317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 01/26/2024] [Accepted: 02/27/2024] [Indexed: 03/06/2024] Open
Abstract
B-cell acute lymphoblastic leukaemia (B-cell ALL) is a common haematologic cancer in children and adults. About 10 percent of children and 50 percent of adults fail to achieve a histological complete remission or subsequently relapse despite current anti-leukaemia drug therapies and/or haematopoietic cell transplants. Several new immune therapies including monoclonal antibodies and chimeric antigen receptor (CAR)-T-cells are proved safe and effective in this setting. We review data on US Food and Drug Administration (FDA)-approved immune therapies for B-cell ALL in children and adults including blinatumomab, inotuzumab ozogamicin, tisagenlecleucel, and brexucabtagene autoleucel. We also summarize pharmaco-dynamics, pharmaco-kinetics, and pharmaco-economics of these interventions.
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Affiliation(s)
- David Kegyes
- Department of Hematology-Medfuture Research Center for Advanced Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj Napoca, Romania; Department of Hematology, Ion Chiricuta Oncology Institute, Cluj Napoca, Romania; Academy of Romanian Scientists, Bucharest, Romania
| | - Gabriel Ghiaur
- Department of Hematology-Medfuture Research Center for Advanced Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj Napoca, Romania; Department of Leukemia, Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University, Baltimore, MD, USA
| | - Anamaria Bancos
- Department of Hematology-Medfuture Research Center for Advanced Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj Napoca, Romania; Department of Hematology, Ion Chiricuta Oncology Institute, Cluj Napoca, Romania
| | - Ciprian Tomuleasa
- Department of Hematology-Medfuture Research Center for Advanced Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj Napoca, Romania; Department of Hematology, Ion Chiricuta Oncology Institute, Cluj Napoca, Romania; Academy of Romanian Scientists, Bucharest, Romania.
| | - Robert Peter Gale
- Centre for Haematology, Imperial College of Science, Technology and Medicine, London, UK; Department of Hematologic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China; Department of Hematology, Peking University People's Hospital, Beijing, China
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Hübel K. Optimizing Real-World Outcomes in High-Risk Relapsed/Refractory (r/r) FL with CAR-T Cell Therapy: A Vodcast and Case Example. Oncol Ther 2024:10.1007/s40487-024-00269-4. [PMID: 38512599 DOI: 10.1007/s40487-024-00269-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 02/28/2024] [Indexed: 03/23/2024] Open
Abstract
Follicular lymphoma (FL) is often considered a chronic disease with frequent relapses, shortening both response duration and survival after every relapse. Selecting the most appropriate therapy at the right time within the treatment timeline is key to optimize outcomes. The aim of this vodcast, featuring Dr. Kai Hübel, is to outline the severity of FL by referring to a patient case as well as highlight chimeric antigen receptor (CAR)-T cells as an effective therapy in relapsed/refractory (r/r) FL. The patient was in their early 50s, diagnosed with FL in the early 2010s and presented with a third relapse. The patient complained of night sweats and fatigue but was still capable of self-care (Eastern Cooperative Oncology Group Performance Status Scale 2). The patient received eight cycles of rituximab-cyclophosphamide-doxorubicin-vincristine-prednisolone (R-CHOP), followed by irradiation and rituximab maintenance (first-line) and then received rituximab 4 × weekly, followed by rituximab maintenance (second-line). The patient relapsed during rituximab maintenance; the patient was rituximab refractory. The patient received six cycles of bendamustine/obinutuzumab followed by obinutuzumab maintenance. The patient relapsed during obinutuzumab maintenance, achieved a partial remission after irradiation and was switched to R/lenalidomide. Due to several high-risk features, CAR-T cell therapy was initiated. Dr. Hubel underlines how earlier treatment with CAR-T cell therapy would have been beneficial for this patient. Results of the ELARA trial as well as comparative studies have shown tisagenlecleucel to be more effective than standard of care in extensively pretreated r/r FL, including high-risk patients. In conclusion, CAR-T cell therapy is a promising therapy option for patients with multiply r/r FL. A vodcast feature is available for this article.
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Affiliation(s)
- Kai Hübel
- Department I of Internal Medicine, Faculty of Medicine, University Hospital Cologne, Cologne, Germany.
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Gagelmann N, Bishop M, Ayuk F, Bethge W, Glass B, Sureda A, Pasquini MC, Kröger N. Axicabtagene Ciloleucel versus Tisagenlecleucel for Relapsed or Refractory Large B Cell Lymphoma: A Systematic Review and Meta-Analysis. Transplant Cell Ther 2024:S2666-6367(24)00171-4. [PMID: 38281590 DOI: 10.1016/j.jtct.2024.01.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/28/2023] [Accepted: 01/23/2024] [Indexed: 01/30/2024]
Abstract
Axicabtagene ciloleucel (axi-cel) and tisagenlecleucel (tisa-cel) are CD19-directed chimeric antigen receptor T cell (CAR-T) therapies approved for relapsed/refractory aggressive large B cell lymphoma (LBCL). Significant costs and complex manufacturing underscore the importance of evidence-based counseling regarding the outcomes of these treatments. With the aim of examining the efficacy and safety of axi-cel versus tisa-cel in patients with relapsed/refractory aggressive LBCL, we performed a systematic literature search of comparative studies evaluating outcomes in relapsed/refractory aggressive LBCL after treatment with axi-cel or tisa-cel. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) for response, progression-free survival (PFS), overall survival (OS), cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and hematotoxicity. Meta-analysis and meta-regression were used to generate summary statistics. A total of 2372 participants were included in the 8 studies in our analysis. The dropout rate between apheresis and infusion was 13% for axi-cel versus 18% for tisa-cel, and the median time from apheresis to infusion was 32 days versus 45 days. Axi-cel showed higher odds for a complete response (OR, 1.65; P < .001) and was associated with higher odds for PFS at 1 year after infusion (OR, .60; P < .001). OS appeared to be improved with axi-cel (OR, .84; 95% CI, .68 to 1.02; P = .08), whereas the cumulative incidence of nonrelapse mortality (NRM) was 11.5% for axi-cel versus 3.7% for tisa-cel (P = .002). The main predictors for survival were lactate dehydrogenase level, Eastern Cooperative Oncology Group Performance Status, and response to bridging, and axi-cel maintained superior efficacy even in elderly patients. In terms of safety, axi-cel was associated with significantly higher odds of any-grade CRS (OR, 3.23; P < .001), but not of grade ≥3 CRS (P = .92). Axi-cel was associated with significantly higher odds of severe ICANS grade ≥3 (OR, 4.03; P < .001). In terms of hematotoxicity, axi-cel was significantly associated with higher odds of severe neutropenia at 1 month after infusion (OR, 2.06; P = .003). As a result, axi-cel was associated with significantly greater resource utilization, including prolonged hospital stay, more frequent intensive care admission, and use of agents such as tocilizumab for toxicity management. We provide strong evidence of the greater efficacy of axi-cel versus tisa-cel in relapsed/refractory aggressive LBCL. The higher toxicity and NRM seen with axi-cel might not counterbalance the overall results, highlighting the need for timely intervention and careful selection of patients, balancing resource utilization and clinical benefit.
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Affiliation(s)
- Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Michael Bishop
- The David and Etta Jonas Center for Cellular Therapy, University of Chicago, Chicago, Illinois
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Bethge
- Department of Hematology and Oncology, University Hospital Tuebingen, Tuebingen, Germany
| | - Bertram Glass
- Department of Hematology and Cell Therapy, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Anna Sureda
- Bellvitge Institute for Biomedical Research, Universitat de Barcelona, Hematology Department, Institut Català d'Oncologia-Hospitalet, Barcelona, Spain
| | - Marcelo C Pasquini
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Mizutani Y, Kusakabe S, Fukushima K, Murakami H, Hamada M, Hasegawa C, Mizuta E, Yamaguchi Y, Nakai R, Kurashige R, Hino A, Ueda T, Fujita J, Miyamura T, Hosen N. [Sequential therapy with inotuzumab ozogamicin followed by CAR T-cell therapy for Philadelphia chromosome-negative acute lymphoblastic leukemia]. Rinsho Ketsueki 2024; 65:78-83. [PMID: 38448002 DOI: 10.11406/rinketsu.65.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
A 25-year-old woman with a history of B-cell acute lymphoblastic leukemia over ten years ago was referred to our hospital with a chief complaint of leukoblastosis. She was participating in a JPLSG (Japanese Pediatric Leukemia/Lymphoma Study Group) clinical study at that time. We diagnosed ALL relapse by multi-color flow cytometric analysis of bone marrow samples at admission, with reference to previous JPLSG data. Because her leukemic cells were resistant to conventional cytotoxic agents, she proceeded to lymphocyte apheresis for chimeric antigen receptor T-cell (CAR-T, Tisagenlecleucel [Tisa-cel]). She received two cycles of inotuzumab ozogamicin as a bridging therapy to Tisa-cel, resulting in a hematological complete remission (minimal residual disease measured by polymerase chain reaction [PCR-MRD] was positive at 1.0×10-4). She was finally administered Tisa-cel and achieved MRD negativity. She is currently in complete remission with careful MRD monitoring. This strategy of sequential bi-targeted therapy combining antibody conjugates and CAR-T cells provides tumor control in deeper remission and minimal damage to organ function through reduced use of cytotoxic anti-tumor agents. Therefore, we believe that this therapeutic strategy is an effective and rational treatment for adolescent and young adult ALL patients.
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Affiliation(s)
- Yo Mizutani
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine
| | - Shinsuke Kusakabe
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine
| | - Kentaro Fukushima
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine
| | - Hiraku Murakami
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine
| | - Masataka Hamada
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine
| | - Chihiro Hasegawa
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine
| | - Emiko Mizuta
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine
| | - Yuta Yamaguchi
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine
| | - Ritsuko Nakai
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine
| | - Ryumei Kurashige
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine
| | - Akihisa Hino
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine
| | - Tomoaki Ueda
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine
| | - Jiro Fujita
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine
| | - Takako Miyamura
- Department of Pediatrics, Osaka University Graduate School of Medicine
| | - Naoki Hosen
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine
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6
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Barsan V, Li Y, Prabhu S, Baggott C, Nguyen K, Pacenta H, Phillips CL, Rossoff J, Stefanski H, Talano JA, Moskop A, Baumeister S, Verneris MR, Myers GD, Karras NA, Cooper S, Qayed M, Hermiston M, Satwani P, Krupski C, Keating A, Fabrizio V, Chinnabhandar V, Kunicki M, Curran KJ, Mackall CL, Laetsch TW, Schultz LM. Tisagenlecleucel utilisation and outcomes across refractory, first relapse and multiply relapsed B-cell acute lymphoblastic leukemia: a retrospective analysis of real-world patterns. EClinicalMedicine 2023; 65:102268. [PMID: 37954907 PMCID: PMC10632672 DOI: 10.1016/j.eclinm.2023.102268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 09/19/2023] [Accepted: 09/26/2023] [Indexed: 11/14/2023] Open
Abstract
Background Tisagenlecleucel was approved by the Food and Drug Administration (FDA) in 2017 for refractory B-cell acute lymphoblastic leukemia (B-ALL) and B-ALL in ≥2nd relapse. Outcomes of patients receiving commercial tisagenlecleucel upon 1st relapse have yet to be established. We aimed to report real-world tisagenlecleucel utilisation patterns and outcomes across indications, specifically including patients treated in 1st relapse, an indication omitted from formal FDA approval. Methods We conducted a retrospective analysis of real-world tisagenlecleucel utilisation patterns across 185 children and young adults treated between August 30, 2017 and March 6, 2020 from centres participating in the Pediatric Real-World CAR Consortium (PRWCC), within the United States. We described definitions of refractory B-ALL used in the real-world setting and categorised patients by reported Chimeric Antigen Receptor (CAR) T-cell indication, including refractory, 1st relapse and ≥2nd relapse B-ALL. We analysed baseline patient characteristics and post-tisagenlecleucel outcomes across defined cohorts. Findings Thirty-six percent (n = 67) of our cohort received tisagenlecleucel following 1st relapse. Of 66 evaluable patients, 56 (85%, 95% CI 74-92%) achieved morphologic complete response. Overall-survival (OS) and event-free survival (EFS) at 1-year were 69%, (95% CI 58-82%) and 49%, (95% CI 37-64%), respectively, with survival outcomes statistically comparable to remaining patients (OS; p = 0.14, EFS; p = 0.39). Notably, toxicity was increased in this cohort, warranting further study. Interestingly, of 30 patients treated for upfront refractory disease, 23 (77%, 95% CI 58-90%) had flow cytometry and/or next-generation sequencing (NGS) minimum residual disease (MRD)-only disease at the end of induction, not meeting the historic morphologic definition of refractory. Interpretation Our findings suggested that tisagenlecleucel response and survival rates overlap across patients treated with upfront refractory B-ALL, B-ALL ≥2nd relapse and B-ALL in 1st relapse. We additionally highlighted that definitions of refractory B-ALL are evolving beyond morphologic measures of residual disease. Funding St. Baldrick's/Stand Up 2 Cancer, Parker Institute for Cancer Immunotherapy, Virginia and D.K. Ludwig Fund for Cancer Research.
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Affiliation(s)
- Valentin Barsan
- Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, 1000 Welch Road, Suite 300, Palo Alto, CA 94304, USA
| | - Yimei Li
- Department of Pediatrics, Children's Hospital of Philadelphia/University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Snehit Prabhu
- Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, 1000 Welch Road, Suite 300, Palo Alto, CA 94304, USA
| | - Christina Baggott
- Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, 1000 Welch Road, Suite 300, Palo Alto, CA 94304, USA
| | - Khanh Nguyen
- Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, 1000 Welch Road, Suite 300, Palo Alto, CA 94304, USA
| | - Holly Pacenta
- Cook Children’s Hospital, 1500 Cooper St 5th Floor, Fort Worth, TX 76104, USA
- Department of Pediatrics, The University of Texas Southwestern Medical Center/Children’s Health, 5323 Harry Hines Blvd., Dallas, TX 75390-9063, USA
| | - Christine L. Phillips
- Department of Pediatrics, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA
- Cincinnati Children’s Hospital Medical Center, Cancer and Blood Disease Institute, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA
| | - Jenna Rossoff
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA
| | - Heather Stefanski
- Division of Pediatric Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota Medical School, 2450 Riverside Ave S AO-102, Minneapolis, MN 55454, USA
| | - Julie-An Talano
- Department of Pediatric Hematology Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA
| | - Amy Moskop
- Department of Pediatric Hematology Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA
| | - Susanne Baumeister
- Dana Farber/Boston Children’s Hospital, 450 Brookline Avenue Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA 02115, USA
| | - Michael R. Verneris
- University of Colorado, Anschutz Medical Campus, Colorado Children’s Hospital, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | | | - Nicole A. Karras
- Department of Pediatrics, City of Hope National Medical Center, 1500 E Duarte Rd, Duarte, CA 91010, USA
| | - Stacy Cooper
- Department of Oncology, Sidney Kimmel Cancer Center at John Hopkins School of Medicine, Baltimore, MD, USA
| | - Muna Qayed
- Emory University and Children’s Healthcare of Atlanta, 2015 Uppergate Drive, Atlanta, GA 30322, USA
| | - Michelle Hermiston
- University of California San Francisco Benioff Children’s Hospital, 1975 4th St., San Francisco, CA 94158, USA
| | - Prakash Satwani
- Division of Pediatric Hematology, Oncology and Stem Cell Transplant, Department of Pediatrics, Columbia University Medical Center, 630 West 168th Street, New York, NY 10032, USA
| | - Christa Krupski
- Department of Pediatrics, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA
- Cincinnati Children’s Hospital Medical Center, Cancer and Blood Disease Institute, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA
| | - Amy Keating
- University of Colorado, Anschutz Medical Campus, Colorado Children’s Hospital, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Vanessa Fabrizio
- University of Colorado, Anschutz Medical Campus, Colorado Children’s Hospital, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Vasant Chinnabhandar
- Division of Pediatric Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota Medical School, 2450 Riverside Ave S AO-102, Minneapolis, MN 55454, USA
| | - Michael Kunicki
- Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, 1000 Welch Road, Suite 300, Palo Alto, CA 94304, USA
| | - Kevin J. Curran
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Crystal L. Mackall
- Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, 1000 Welch Road, Suite 300, Palo Alto, CA 94304, USA
- Center for Cancer Cell Therapy, Stanford University School of Medicine, Stanford Cancer Institute, 265 Campus Drive, Stanford, CA 94305, USA
- Division of Blood and Bone Marrow Transplantation, Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Room H0101, Stanford, CA 94305-5623, USA
| | - Theodore W. Laetsch
- Department of Pediatrics, Children's Hospital of Philadelphia/University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Liora M. Schultz
- Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, 1000 Welch Road, Suite 300, Palo Alto, CA 94304, USA
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Terao T, Kitamura W, Fujii N, Asada N, Kamoi C, Fujiwara K, Kondo K, Matsubara C, Hayashino K, Seike K, Fujiwara H, Ennishi D, Nishimori H, Fujii K, Matsuoka KI, Maeda Y. Negative Prognostic Impact of High-Dose or Long-Term Corticosteroid Use in Patients with Relapsed or Refractory B-Cell Lymphoma Who Received Tisagenlecleucel. Transplant Cell Ther 2023; 29:573.e1-573.e8. [PMID: 37394114 DOI: 10.1016/j.jtct.2023.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/12/2023] [Accepted: 06/28/2023] [Indexed: 07/04/2023]
Abstract
The prognostic impact of corticosteroid therapy in patients receiving tisagenlecleucel (tisa-cel) treatment who are more likely to develop cytokine release syndrome (CRS) remains unclear. This study aimed to evaluate the clinical impact and lymphocyte kinetics of corticosteroid administration for CRS in 45 patients with relapsed and/or refractory B-cell lymphoma treated with tisa-cel. This was a retrospective evaluation of all consecutive patients diagnosed with relapsed and/or refractory diffuse large B-cell lymphoma, follicular lymphoma with histologic transformation to large B-cell lymphoma, or follicular lymphoma who received commercial-based tisa-cel treatment. The best overall response rate, complete response rate, median progression-free survival (PFS), and median overall survival (OS) were 72.7%, 45.5%, 6.6 months, and 15.3 months, respectively. CRS (predominantly grade 1/2) occurred in 40 patients (88.9%), and immune effector cell-associated neurotoxicity syndrome (ICANS) of all grades occurred in 3 patients (6.7%). No grade ≥3 ICANS occurred. Patients with high-dose (≥524 mg, methylprednisolone equivalent; n = 12) or long-term (≥8 days; n = 9) corticosteroid use had inferior PFS and OS to patients with low-dose or no corticosteroid use (both P < .05). The prognostic impact remained even in 23 patients with stable disease (SD) or progressive disease (PD) before tisa-cel infusion (P = .015). but not in patients with better disease status (P = .71). The timing of corticosteroid initiation did not have a prognostic impact. Multivariate analysis identified high-dose corticosteroid use and long-term corticosteroid use as independent prognostic factors for PFS and OS, respectively, after adjusting for elevated lactate dehydrogenase level before lymphodepletion chemotherapy and disease status (SD or PD). Lymphocyte kinetics analysis demonstrated that after methylprednisolone administration, the proportions of regulatory T cells (Tregs), CD4+ central memory T (TCM) cells, and natural killer (NK) cells were decreased, whereas the proportion of CD4+ effector memory T (TEM) cells was increased. Patients with a higher proportion of Tregs at day 7 had a lower incidence of CRS, but this did not affect prognosis, indicating that early elevation of Tregs may serve as a biomarker for CRS development. Furthermore, patients with higher numbers of CD4+ TCM cells and NK cells at various time points had significantly better PFS and OS, whereas the number of CD4+ TEM cells did not impact prognostic outcomes. This study suggests that high-dose or long-term corticosteroid use attenuates the efficacy of tisa-cel, especially in patients with SD or PD. Additionally, patients with high levels of CD4+ TCM cells and NK cells after tisa-cel infusion had longer PFS and OS.
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Affiliation(s)
- Toshiki Terao
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan; Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Wataru Kitamura
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan; Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Nobuharu Fujii
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan; Division of Blood Transfusion, Okayama University Hospital, Okayama, Japan.
| | - Noboru Asada
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Chihiro Kamoi
- Division of Blood Transfusion, Okayama University Hospital, Okayama, Japan
| | - Kanako Fujiwara
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Kaho Kondo
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Chisato Matsubara
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Kenta Hayashino
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Keisuke Seike
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Hideaki Fujiwara
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Daisuke Ennishi
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Hisakazu Nishimori
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Keiko Fujii
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan; Division of Clinical Laboratory, Okayama University Hospital, Okayama, Japan
| | - Ken-Ichi Matsuoka
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Yoshinobu Maeda
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan; Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Saha A, Jhaveri K, Sarfraz H, Chavez JC. Tisagenlecleucel: CAR-T cell therapy for adult patients with relapsed or refractory follicular lymphoma. Expert Opin Biol Ther 2023; 23:869-876. [PMID: 37599463 DOI: 10.1080/14712598.2023.2248878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 08/14/2023] [Indexed: 08/22/2023]
Abstract
INTRODUCTION Tisagenlecleucel (tisa-cel) is an anti CD19 CAR-T therapy that has demonstrated clinical activity in R/R large B-cell lymphoma and R/R B-cell acute lymphoblastic leukemia. It showed particularly high efficacy in R/R follicular lymphoma (FL) with a manageable toxicity profile. The pivotal ELARA study in R/R FL confirmed these findings and led to the FDA approval of tisa-cel in R/R FL after two lines of systemic therapies. AREAS COVERED We start with an introduction of FL and the current treatment landscape with emphasis on the R/R setting. We review the role of CAR-T in R/R FL with focus on currently available products. We describe the ELARA study at a high level to give a perspective of the patient population that was treated. Finally, we discuss aspects related to product selection and whether bispecific antibodies will challenge the role of CAR-T in FL given their similar efficacy. EXPERT OPINION Tisa-cel is a highly effective therapy for heavily pretreated R/R FL with a toxicity profile that is low grade and manageable. Durable remissions (including high-risk patients) are seen in the pivotal ELARA study. Clinicians should consider early referral of R/R FL patients for assessment and discussion.
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Affiliation(s)
- Aditi Saha
- Department of Medicine/Hematology Oncology, University of South Florida, Tampa, FLUSA
| | - Khushali Jhaveri
- Department of Medicine/Hematology Oncology, University of South Florida, Tampa, FLUSA
| | - Humaira Sarfraz
- Department of Medicine/Hematology Oncology, University of South Florida, Tampa, FLUSA
| | - Julio C Chavez
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL USA
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10
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Parker C, Liu FF, Deger KA, Franco-Villalobos C, Proskorovsky I, Keating SJ, Sorensen S. Cost-Effectiveness of Lisocabtagene Maraleucel Versus Axicabtagene Ciloleucel and Tisagenlecleucel in the Third-Line or Later Treatment Setting for Relapsed or Refractory Large B-cell Lymphoma in the United States. Adv Ther 2023; 40:2355-2374. [PMID: 36947328 PMCID: PMC10129927 DOI: 10.1007/s12325-023-02444-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/26/2023] [Indexed: 03/23/2023]
Abstract
INTRODUCTION The objective of this study was to evaluate the cost-effectiveness of lisocabtagene maraleucel (liso-cel) versus other available chimeric antigen receptor T-cell therapies, including axicabtagene ciloleucel (axi-cel) and tisagenlecleucel (tisa-cel), in patients who had received at least two prior therapies from a United States (US) commercial third-party payer perspective. METHODS To capture this heterogeneity in survival outcomes, we used mixture cure models to extrapolate progression-free survival (PFS) and overall survival (OS). Patient-level data from TRANSCEND NHL 001 for liso-cel and reconstructed patient-level data from ZUMA-1 for axi-cel, JULIET for tisa-cel, and SCHOLAR-1 for salvage chemotherapy, derived using the Guyot method, were used for OS and PFS. The model included adverse events associated with liso-cel, axi-cel, and tisa-cel. RESULTS Liso-cel was less costly (incremental cost of - $74,980) and marginally more effective (0.002 incremental quality-adjusted life-years [QALY]) than axi-cel and had an incremental cost of $67,925 and 2.02 incremental QALYs over tisa-cel in the base case. Results remained consistent in sensitivity analyses, with the liso-cel OS cure fraction being the main driver of cost-effectiveness compared with both axi-cel and tisa-cel. CONCLUSION This analysis estimated that liso-cel is cost-effective compared with tisa-cel and axi-cel from a commercial US payer perspective.
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Affiliation(s)
| | | | - Kristen A Deger
- Evidence Synthesis, Modeling & Communication, Evidera Inc., 7101 Wisconsin Avenue, Suite 1400, Bethesda, MD, 20814, USA
| | | | - Irina Proskorovsky
- Evidence Synthesis, Modeling & Communication, Evidera Inc., Montreal, QC, Canada
| | | | - Sonja Sorensen
- Evidence Synthesis, Modeling & Communication, Evidera Inc., 7101 Wisconsin Avenue, Suite 1400, Bethesda, MD, 20814, USA.
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Goto H, Kitawaki T, Fujii N, Kato K, Onishi Y, Fukuhara N, Yamauchi T, Toratani K, Kobayashi H, Yoshida S, Shimo M, Onodera K, Senjo H, Onozawa M, Hirata K, Yokota I, Teshima T. Safety and efficacy of tisagenlecleucel in patients with relapsed or refractory B-cell lymphoma: the first real-world evidence in Japan. Int J Clin Oncol 2023; 28:816-826. [PMID: 37071252 DOI: 10.1007/s10147-023-02334-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/28/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Tisagenlecleucel, an autologous CD19-directed T-cell immunotherapy, can induce a durable response in adult patients with relapsed/refractory (r/r) B-cell lymphoma. METHODS To elucidate the outcome of chimeric antigen receptor (CAR) T-cell therapy in Japanese, we retrospectively analyzed the outcomes of 89 patients who received tisagenlecleucel for r/r diffuse large B-cell lymphoma (n = 71) or transformed follicular lymphoma (n = 18). RESULTS With a median follow-up of 6.6-months, 65 (73.0%) patients achieved a clinical response. The overall survival (OS) and event-free survival (EFS) rates at 12 months were 67.0% and 46.3%, respectively. Overall, 80 patients (89.9%) had cytokine release syndrome (CRS), and 6 patients (6.7%) had a grade ≥ 3 event. ICANS occurred in 5 patients (5.6%); only 1 patient had grade 4 ICANS. Representative infectious events of any grade were cytomegalovirus viremia, bacteremia and sepsis. The most common other adverse events were ALT elevation, AST elevation, diarrhea, edema, and creatinine elevation. No treatment-related mortality was observed. A Sub-analysis showed that a high metabolic tumor volume (MTV; ≥ 80 ml) and stable disease /progressive disease before tisagenlecleucel infusion were both significantly associated with a poor EFS and OS in a multivariate analysis (P < 0.05). Notably, the combination of these 2 factors efficiently stratified the prognosis of these patients (HR 6.87 [95% CI 2.4-19.65; P < 0.05] into a high-risk group). CONCLUSION We report the first real-world data on tisagenlecleucel for r/r B-cell lymphoma in Japan. Tisagenlecleucel is feasible and effective, even in late line treatment. In addition, our results support a new algorithm for predicting the outcomes of tisagenlecleucel.
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Affiliation(s)
- Hideki Goto
- Division of Laboratory and Transfusion Medicine, Hokkaido University Hospital, Sapporo, Japan.
| | - Toshio Kitawaki
- Department of Hematology and Oncology, Kyoto University Hospital, Kyoto, Japan
| | - Nobuharu Fujii
- Division of Transfusion, Okayama University Hospital, Okayama, Japan
| | - Koji Kato
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yasushi Onishi
- Department of Hematology, Tohoku University Hospital, Sendai, Japan
| | - Noriko Fukuhara
- Department of Hematology, Tohoku University Hospital, Sendai, Japan
| | - Takuji Yamauchi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Kazunori Toratani
- Department of Hematology and Oncology, Kyoto University Hospital, Kyoto, Japan
| | - Hiroki Kobayashi
- Department of Hematology, Oncology and Respiratory Medicine, Graduate School of Medicine, Density and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Shota Yoshida
- Department of Hematology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Masatoshi Shimo
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Koichi Onodera
- Department of Hematology, Tohoku University Hospital, Sendai, Japan
| | - Hajime Senjo
- Department of Hematology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Masahiro Onozawa
- Department of Hematology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Kenji Hirata
- Department of Diagnostic Imaging, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Isao Yokota
- Department of Biostatistics, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Takanori Teshima
- Division of Laboratory and Transfusion Medicine, Hokkaido University Hospital, Sapporo, Japan
- Department of Hematology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
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12
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Benoit A, B Boies MH, Déry N, M Garcia L, Simard M, Poirier M, Delage R, Lortal Canguilhem B, Doyle C, Larouche JF, Couture F, Lemieux C. CAR T-Cells for the Treatment of Refractory or Relapsed Large B-Cell Lymphoma: A Single-Center Retrospective Canadian Study. Clin Lymphoma Myeloma Leuk 2023; 23:203-210. [PMID: 36646606 DOI: 10.1016/j.clml.2022.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 12/18/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Chimeric antigen receptor (CAR) T-cells are an important new third-line treatment option for large B-cell lymphoma (LBCL). The objective response rates in pivotal early phase clinical trials with CAR T-cells were very promising. The objective of this study was to describe the efficacy results obtained with CAR T-cells infusions in our institution and to compare the toxicities of our cohort with those of pivotal trials and studies conducted in a real-life setting. PATIENTS AND METHODS Efficacy and safety data were retrospectively collected from 25 patients with LBCL treated with CAR T-cells therapy at CHU de Québec-Université Laval. A literature search was then performed to identify other efficacy or safety data from a real-life setting. RESULTS At 3 months post infusion, the objective response rate (ORR) in our population with tisagenlecleucel and axicabtagene-ciloleucel were 20% and 47%, respectively. Bulky disease was the only negative predictor of poor response at 3 months (0% vs. 53%, P = .03). Bulky disease was associated with a median PFS of 2 months compared to 5 months for non-bulky disease (P = .0009). Grade ≥ 3 hematological toxicities were greater in patients treated with axi-cel (60% vs. 20%, P = .048), without bone marrow involvement (55% vs. 0%, P =.046), without stage IV disease (72% vs. 21%, P =.02), with refractory disease (67% vs. 10%, P =.01) or having been affected by cytokine release syndrome (58% vs. 0%, P =.02). CONCLUSION The poor response rate at 3 months after infusion in our cohort was influenced mainly by bulky disease. Further studies are needed to better characterize the loss of efficacy of CAR T-cells because the majority of patients will relapse over time.
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Affiliation(s)
- Aurélie Benoit
- Department of pharmacy, CHU de Québec - Université Laval, Québec, Québec, Canada; Faculté de pharmacie, Université de Bordeaux, Bordeaux, Nouvelle Aquitaine, France; Unité pour l'usage optimal du médicament et la recherche (UGMR), CHU de Québec - Université Laval, Québec, Québec, Canada
| | - Marie-Hélène B Boies
- Department of pharmacy, CHU de Québec - Université Laval, Québec, Québec, Canada; Unité pour l'usage optimal du médicament et la recherche (UGMR), CHU de Québec - Université Laval, Québec, Québec, Canada
| | - Nicole Déry
- Department of pharmacy, CHU de Québec - Université Laval, Québec, Québec, Canada; Unité pour l'usage optimal du médicament et la recherche (UGMR), CHU de Québec - Université Laval, Québec, Québec, Canada
| | - Luciana M Garcia
- Department of medicine, CHU de Québec - Université Laval, Québec, Québec, Canada
| | - Mélanie Simard
- Department of pharmacy, CHU de Québec - Université Laval, Québec, Québec, Canada
| | - Mireille Poirier
- Department of pharmacy, CHU de Québec - Université Laval, Québec, Québec, Canada
| | - Robert Delage
- Department of medicine, CHU de Québec - Université Laval, Québec, Québec, Canada
| | | | - Catherine Doyle
- Department of medicine, CHU de Québec - Université Laval, Québec, Québec, Canada
| | | | - Félix Couture
- Department of medicine, CHU de Québec - Université Laval, Québec, Québec, Canada
| | - Christopher Lemieux
- Department of medicine, CHU de Québec - Université Laval, Québec, Québec, Canada.
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13
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Kegyes D, Jitaru C, Ghiaur G, Ciurea S, Hoelzer D, Tomuleasa C, Gale RP. Switching from salvage chemotherapy to immunotherapy in adult B-cell acute lymphoblastic leukemia. Blood Rev 2023; 59:101042. [PMID: 36732205 DOI: 10.1016/j.blre.2023.101042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/27/2022] [Accepted: 01/18/2023] [Indexed: 01/21/2023]
Abstract
About one-half of adults with acute B-cell lymphoblastic leukemia (B-ALL) who do not achieve molecular complete remission or who subsequently relapse are not cured by current chemo- or targeted therapies. Previously, the sole therapeutic option for such persons was a hematopoietic stem cell transplant. Recently, several immune therapies including monoclonal antibodies, bispecific T-cell engagers (BiTEs), antibody-drug conjugates (ADCs), and chimeric antigen receptor T-cells (CARs) have been shown safe and effective in this setting. In this manuscript, we summarize data on US FDA-approved immune therapies of advanced adult B-ALL including rituximab, blinatumomab, inotuzumab ozogamicin, tisagenlecleucel and brexucabtagene autoleucel. We consider the results of clinical trials focusing on efficacy, safety, and quality of life (QoL). Real-world evidence is presented as well. We also briefly discuss pharmacodynamics, pharmacokinetics, and pharmacoeconomics followed by risk-benefit analyses. Lastly, we present future directions of immune therapies for advanced B-ALL in adults.
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Affiliation(s)
- David Kegyes
- Department of Hematology-Medfuture Research Center for Advanced Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj Napoca, Romania; Department of Hematology, Ion Chiricuta Oncology Institute, Cluj Napoca, Romania
| | - Ciprian Jitaru
- Department of Hematology-Medfuture Research Center for Advanced Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj Napoca, Romania; Department of Hematology, Ion Chiricuta Oncology Institute, Cluj Napoca, Romania
| | - Gabriel Ghiaur
- Department of Hematology-Medfuture Research Center for Advanced Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj Napoca, Romania; Department of Leukemia, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Stefan Ciurea
- Department of Stem Cell Transplant and Cellular Therapies, University of California, Irvine, CA, USA
| | - Dieter Hoelzer
- Department of Medicine, Goethe University, Frankfurt, Germany
| | - Ciprian Tomuleasa
- Department of Hematology-Medfuture Research Center for Advanced Medicine, Iuliu Hațieganu University of Medicine and Pharmacy Cluj Napoca, Romania; Department of Hematology, Ion Chiricuta Oncology Institute, Cluj Napoca, Romania.
| | - Robert Peter Gale
- Centre for Haematology, Imperial College of Science, Technology and Medicine, London, UK; Department of Hematologic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
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Fowler NH, Dickinson M, Ghosh M, Chen AI, Andreadis C, Tiwari R, Masood A, Ramos R, Jousseaume E, Thieblemont C, Dreyling M, Schuster SJ. Assessment of Healthcare Resource Utilization and Hospitalization Costs in Patients With Relapsed or Refractory Follicular Lymphoma Undergoing CAR-T Cell Therapy With Tisagenlecleucel: Results From the ELARA Study. Transplant Cell Ther 2023; 29:60.e1-60.e4. [PMID: 36182104 DOI: 10.1016/j.jtct.2022.09.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/12/2022] [Accepted: 09/22/2022] [Indexed: 02/09/2023]
Abstract
Follicular lymphoma (FL) is generally considered an indolent disease, although patients with relapsing FL experience progressively shorter durations of response to second or later lines of therapy. The ongoing ELARA trial in adult patients with relapsed/refractory (r/r) FL treated with tisagenlecleucel demonstrated an overall response rate of 86.2% and a complete response rate of 69.1%, with no treatment-related deaths. Tisagenlecleucel was administered in the outpatient setting in 18% of patients in ELARA; however, there is limited knowledge concerning the impact of inpatient versus outpatient tisagenlecleucel administration on healthcare resource utilization (HCRU) among patients with r/r FL. Here, we present the first HCRU analysis among patients with r/r FL who received tisagenlecleucel in the Phase II, single-arm, multicenter ELARA trial. HCRU was characterized using hospitalization data from day 1 to month 2 after tisagenlecleucel infusion. Information on length of stay, facility use, and discharge was assessed in patients who received tisagenlecleucel in the outpatient or inpatient setting. All costs were inflated to 2020 US dollars. As of August 3, 2021 (20-month median follow-up), 17/97 (18%) r/r FL patients were infused in an outpatient setting. Patients infused in the outpatient setting generally had favorable Eastern Cooperative Oncology Group performance status and Follicular Lymphoma International Prognostic Index scores, and less bulky disease at baseline. However, the outpatients had higher proportions of patients with grade 3A FL, primary refractory disease, and >5 lines of prior therapy compared with inpatients. Forty-one percent of patients treated in the outpatient setting did not require hospitalization within 30 days after infusion, and outpatients who did require hospitalization had a shorter average length of stay compared with inpatients (5 versus 13 days). No outpatients required intensive care unit (ICU) admission, whereas 9% of inpatients were admitted to the ICU. The mean postinfusion hospitalization costs were $7477 and $40,054 in the outpatient and inpatient settings, respectively. Efficacy between both groups was similar. Tisagenlecleucel can be safely administered to some patients in the outpatient setting, which may reduce HCRU for patients with r/r FL.
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Affiliation(s)
- Nathan Hale Fowler
- The University of Texas MD Anderson Cancer Center, Houston, Texas; BostonGene, Waltham, Massachusetts.
| | - Michael Dickinson
- Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, and the Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Monalisa Ghosh
- Michigan Medicine University of Michigan, Ann Arbor, Michigan
| | - Andy I Chen
- Oregon Health and Science University, Portland, Oregon
| | - Charalambos Andreadis
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
| | - Ranjan Tiwari
- Novartis Healthcare Pvt. Ltd, Hyderabad, Telangana, India
| | - Aisha Masood
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Roberto Ramos
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | | | - Martin Dreyling
- Klinikum Der Universität München-Grosshadern, Medizinische Klinik und Poliklinik III, München, Germany
| | - Stephen J Schuster
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
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Asghar N, Masood A, Dhaliwal A, Khurana S, Davis J, Hashmi H, Husnain M. Chimeric Antigen Receptor T-Cell (CAR T-Cell) Therapy for Primary and Secondary Central Nervous System Lymphoma: A Systematic Review of Literature. Clin Lymphoma Myeloma Leuk 2023; 23:15-21. [PMID: 36328891 DOI: 10.1016/j.clml.2022.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/21/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022]
Abstract
Relapsed/refractory central nervous system (CNS) lymphoma, whether primary or secondary, is associated with poor prognosis with currently available treatment modalities, including high-dose chemotherapy-autologous stem cell transplantation. The pivotal ZUMA-1 and JULIET trials that led to FDA approval of Axicabtagene ciloleucel and Tisagenlecleucel for relapsed refractory large cell lymphoma excluded patients with CNS involvement due to concerns of increased toxicity. However, TRANSCEND study for Lisocabtagene maraleucel in relapsed refractory large cell lymphoma allowed patients with CNS involvement and reported manageable CNS toxicities in these patients. In the real-world experience, chimeric antigen receptor T-cell (CAR T) therapy has been deemed safe and effective for these patients with poor prognosis. In this systematic review, we analyzed available literature to evaluate the role of CAR T-cell therapy in both primary and secondary CNS lymphoma using Embase, Cochrane, and PubMed databases. A total of 14 studies, including 8 retrospective analyses and 6 prospective studies/clinical trials, were included in the qualitative synthesis to study the safety and efficacy of CAR T. Based on our analysis, CAR T-cell therapy appears to be associated with reasonable efficacy and a manageable safety for primary and secondary CNS lymphoma.
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16
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Sakaguchi H. [CAR-T therapy for pediatric acute lymphoblastic leukemia]. Rinsho Ketsueki 2023; 64:1440-1446. [PMID: 38072432 DOI: 10.11406/rinketsu.64.1440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The prognosis of B-cell acute lymphoblastic leukemia in children, adolescents, and young adults has improved significantly over the second half of the last century, with long-term survival rates reaching 90%, due to risk factor stratification and risk-adjusted treatment intensity. On the contrary, there are relapsed/refractory cases, and antibody-mediated immunotherapy and chimeric antigen receptor T-cell therapy are now being used in combination with conventional chemotherapy and allogeneic hematopoietic cell transplantation; the development of this treatment is expected. Tisagenlecleucel is extensively used in Japan and abroad because of its high complete remission rate in high-risk relapsed/refractory cases, including unresponsive to chemotherapy, relapsed after transplantation, and transplant-unsuitable cases. Several studies have been published in the last 2-3 years that discuss risk factors for relapse after tisagenlecleucel and the need for consolidative therapy. This manuscript presents the direction of these discussions and perspectives.
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Affiliation(s)
- Hirotoshi Sakaguchi
- Division of Transplantation and Cellular Therapy, Children's Medical Center, National Center for Child Health and Development
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17
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Jo T, Henzan T, Tomizawa D, Yoshihara S, Kahata K, Yamada-Fujiwara M, Okuyama Y, Shiba N, Fujii K, Umezawa Y, Yamazaki R, Takeda W, Hanajiri R, Fukushima K, Mimura N, Ikemoto J, Iwaki K, Yonetani N, Fujiwara SI, Ri M, Nagamura-Inoue T, Tanosaki R, Arai Y. [Manufacturing results of tisagenlecleucel for acute lymphoblastic leukemia: a survey by the CAR-T cell therapy taskforce of the Japan Society of Transfusion Medicine and Cell Therapy]. Rinsho Ketsueki 2023; 64:331-337. [PMID: 37271521 DOI: 10.11406/rinketsu.64.331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The frequency of the manufacturing failure of chimeric antigen receptor (CAR)-T cell therapy in clinical practice is unknown. To clarify the current state of how likely CAR-T cell production is to succeed or fail for B-cell acute lymphoblastic leukemia (B-ALL), we analyzed cases in which the production of tisagenlecleucel was performed for patients with B-ALL at 15 facilities in Japan from October 2019 to March 2022. Total 81 patients (47 males and 34 females) were analyzed. The median age at apheresis was 13 years (1-25) with a median number of prior treatments of 4 (1-9). The numbers of patients with histories of allogeneic transplantation, inotuzumab ozogamicin, or blinatumomab treatments were 51 (63.0%), 26 (32.1%), and 37 (45.7%), respectively. The median blast percentage and CD3+ cell counts in peripheral blood were 0% (0-91.5), and 611/µl (35-4,210) at apheresis, and the median number of CD3+ cells shipped was 2.2×109 (0.5-8.3). While cases with a history of heavy prior treatment before apheresis were included, no manufacturing failures were observed. Continuing to monitor the status of manufacturing failures is necessary as the number of B-ALL cases treated with CAR-T cell therapy increases.
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Affiliation(s)
- Tomoyasu Jo
- Department of Clinical Laboratory Medicine and Center for Research and Application of Cellular Therapy, Kyoto University Hospital
- Department of Hematology and Oncology, Kyoto University Hospital
| | - Tomoko Henzan
- Center for Cellular and Molecular Medicine, Kyushu University Hospital
| | - Daisuke Tomizawa
- Children's Cancer Center, National Center for Child Health and Development
| | - Satoru Yoshihara
- Department of Cellular Therapy and Transfusion Medicine, Hyogo Medical University Hospital
- Department of Hematology, Hyogo Medical University Hospital
| | - Kaoru Kahata
- Department of Hematology, Hokkaido University Faculty of Medicine
| | | | - Yoshiki Okuyama
- Division of Transfusion and Cell Therapy, Tokyo Metropolitan Komagome Hospital
| | - Norio Shiba
- Department of Division of Blood Transfusion and Cell Therapy, Yokohama City University
| | - Keiko Fujii
- Division of Transfusion, Okayama University Hospital
| | | | - Rie Yamazaki
- Center for Transfusion Medicine and Cell Therapy, Keio University School of Medicine
| | - Wataru Takeda
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital
| | - Ryo Hanajiri
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine
| | - Kentaro Fukushima
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine
| | - Naoya Mimura
- Department of Transfusion Medicine and Cell Therapy, Chiba University Hospital
| | - Junko Ikemoto
- Department of Cellular Therapy and Transfusion Medicine, Hyogo Medical University Hospital
| | - Keita Iwaki
- Division of Blood Transfusion and Cell Therapy, Tohoku University Hospital
| | - Noboru Yonetani
- Department of Hematology, Kobe City Medical Center General Hospital
| | - Shin-Ichiro Fujiwara
- Division of Cell Transplantation and Transfusion, Jichi Medical University Hospital
| | - Masaki Ri
- Department of Hematology and Oncology, Nagoya City University Graduate School of Medical Sciences
| | - Tokiko Nagamura-Inoue
- Department of Cell Processing and Transfusion, The Institute of Medical Science, The University of Tokyo
| | - Ryuji Tanosaki
- Center for Transfusion Medicine and Cell Therapy, Keio University School of Medicine
| | - Yasuyuki Arai
- Department of Clinical Laboratory Medicine and Center for Research and Application of Cellular Therapy, Kyoto University Hospital
- Department of Hematology and Oncology, Kyoto University Hospital
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18
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Fukuhara N, Kato K, Goto H, Takeshi T, Kawaguchi M, Tokushige K, Akashi K, Teshima T, Harigae H, Schuster SJ, Thieblemont C, Dreyling M, Fowler N. Efficacy and safety of tisagenlecleucel in adult Japanese patients with relapsed or refractory follicular lymphoma: results from the phase 2 ELARA trial. Int J Hematol 2023; 117:251-259. [PMID: 36404384 PMCID: PMC9889457 DOI: 10.1007/s12185-022-03481-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Tisagenlecleucel yielded a high durable response rate in patients with relapsed/refractory (r/r) follicular lymphoma (FL) in the global phase 2 ELARA trial. Here, we report the efficacy, safety, and cellular kinetics of tisagenlecleucel in a subgroup of Japanese patients with r/r FL from ELARA. METHODS ELARA (NCT03568461) is a global single-arm trial of tisagenlecleucel in patients with r/r FL who received ≥ 2 prior lines of therapy. The primary endpoint was the complete response rate (CRR), and the secondary endpoints were the overall response rate, duration of response, progression-free survival, overall survival, safety, and cellular kinetics. RESULTS As of March 29, 2021, nine Japanese patients were enrolled and received tisagenlecleucel with a median follow-up of 13.6 months (range, 10.5‒19.3). Per independent review committee, CRR was 100% (95% CI 63.1‒100). Within 8 weeks of infusion, cytokine release syndrome (CRS) of any grade was reported in 6 patients (66.7%); however, no grade ≥ 3 CRS or any grade serious neurological events or treatment-related deaths were observed. CONCLUSION Tisagenlecleucel showed high efficacy and manageable safety in adult Japanese patients with r/r FL. Moreover, the clinical outcomes were similar to the global population, which supports the potential of tisagenlecleucel in Japanese patients with r/r FL.
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Affiliation(s)
- Noriko Fukuhara
- Department of Hematology, Tohoku University Hospital, 1-1 Seiryo-cho, Sendai, 980-8574 Japan
| | - Koji Kato
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Hideki Goto
- Department of Hematology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | | | | | | | - Koichi Akashi
- Department of Hematology, Tohoku University Hospital, 1-1 Seiryo-cho, Sendai, 980-8574 Japan
| | - Takanori Teshima
- Department of Hematology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hideo Harigae
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | | | | | - Martin Dreyling
- Department of Internal Medicine III, LMU Hospital, Munich, Germany
| | - Nathan Fowler
- The University of Texas MD Anderson Cancer Center, Houston, TX USA ,BostonGene, Waltham, MA USA
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19
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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] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [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. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-022-02188-0.
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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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20
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Cartron G, Fox CP, Liu FF, Kostic A, Hasskarl J, Li D, Bonner A, Zhang Y, Maloney DG, Kuruvilla J. Matching-adjusted indirect treatment comparison of chimeric antigen receptor T-cell therapies for third-line or later treatment of relapsed or refractory large B-cell lymphoma: lisocabtagene maraleucel versus tisagenlecleucel. Exp Hematol Oncol 2022; 11:17. [PMID: 35337365 PMCID: PMC8953336 DOI: 10.1186/s40164-022-00268-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/21/2022] [Indexed: 12/23/2022] Open
Abstract
Background There are no head-to-head clinical studies comparing chimeric antigen receptor (CAR) T-cell therapies for the treatment of relapsed or refractory aggressive large B-cell lymphomas. Naive, indirect comparisons may be inappropriate, as the study designs and patient populations could differ substantially. Matching-adjusted indirect comparisons (MAIC) can reduce many biases associated with indirect comparisons between studies. To determine the comparative efficacy and safety of lisocabtagene maraleucel (liso-cel) to tisagenlecleucel, we describe an unanchored MAIC of the pivotal studies TRANSCEND NHL 001 (TRANSCEND; NCT02631044; liso-cel) and JULIET (NCT02445248; tisagenlecleucel). Methods Individual patient data (IPD) from TRANSCEND were available to the authors; for the JULIET pivotal study, summary-level data from the published study were used. To balance the populations between two studies, IPD from TRANSCEND were adjusted to match the marginal distribution (e.g., mean, variance) of clinical factors among patients from JULIET. Results Results from the primary MAIC showed liso-cel had statistically significant greater efficacy than tisagenlecleucel (objective response rate: odds ratio [OR] = 2.78, 95% confidence interval [CI]: 1.63‒4.74; complete response rate: OR = 2.01, 95% CI: 1.22‒3.30; progression-free survival: hazard ratio [HR] = 0.65, 95% CI: 0.47‒0.91; overall survival: HR = 0.67, 95% CI: 0.47‒0.95). MAIC of safety outcomes showed lower ORs for all-grade and grade ≥ 3 cytokine release syndrome, and grade ≥ 3 prolonged cytopenia for liso-cel when compared with tisagenlecleucel; there were no statistically significant differences detected for other safety outcomes. Conclusions Overall, this MAIC of two CAR T-cell therapies indicates liso-cel had favorable efficacy and a comparable or better safety profile relative to tisagenlecleucel. Clinical trial registration: ClinicalTrials.gov identifiers: NCT02631044 and NCT02445248. Supplementary Information The online version contains supplementary material available at 10.1186/s40164-022-00268-z.
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Affiliation(s)
- Guillaume Cartron
- Montpellier University Hospital Center, 80 Avenue Augustin Fliche, Montpellier, France.
| | | | | | | | - Jens Hasskarl
- Celgene, a Bristol-Myers Squibb Company, Boudry, Switzerland
| | - Daniel Li
- Bristol Myers Squibb, Princeton, NJ, USA
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21
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Shahid S, Ramaswamy K, Flynn J, Mauguen A, Perica K, Park JH, Forlenza CJ, Shukla NN, Steinherz PG, Margossian SP, Boelens JJ, Kernan NA, Curran KJ. Impact of Bridging Chemotherapy on Clinical Outcomes of CD19-Specific CAR T Cell Therapy in Children/Young Adults with Relapsed/Refractory B Cell Acute Lymphoblastic Leukemia. Transplant Cell Ther 2022; 28:72.e1-8. [PMID: 34852305 DOI: 10.1016/j.jtct.2021.11.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 02/03/2023]
Abstract
Chimeric antigen receptor (CAR) T cells achieve response and durable remission in patients with relapsed/refractory (R/R) B cell malignancies. Following collection of patient T cells, chemotherapy ("bridging chemotherapy") is utilized during the manufacture of CAR T cells. However, the optimal bridging chemotherapy has yet to be defined. Our objective in this study was to report clinical outcomes following bridging chemotherapy in a cohort of pediatric/young adult patients with R/R B cell acute lymphoblastic leukemia (B-ALL) treated with CAR T cell therapy. This retrospective study included patients enrolled on clinical trial NCT01860937 or referred to Memorial Sloan Kettering Cancer Center for commercial CAR T cell therapy (tisagenlecleucel). Bridging chemotherapy (given after T cell collection and before CAR T cell infusion) was defined as high intensity if myelosuppression was expected for >7 days. Outcome comparison analyses were performed in high-intensity versus low-intensity bridging chemotherapy, 1 cycle versus ≥2 cycles of bridging chemotherapy, disease burden at the start of bridging chemotherapy, disease burden at the start of bridging chemotherapy with chemotherapy intensity, tumor debulking by bridging chemotherapy, and disease burden pre-lymphodepleting chemotherapy (LDC) for CAR T cell treatment. The outcomes of this analysis showed that the incidence of grade ≥3 infection was significantly higher (94% versus 56%; P = .019) and overall survival (OS) was significantly lower (hazard ratio, 3.73; 95% confidence interval, 1.39 to 9.97; P = .006) in patients who received ≥2 cycles versus 1 cycle of bridging chemotherapy. No difference in incidence was found for cytokine release syndrome (P > .99) or neurotoxicity/immune effector cell-associated neurotoxicity syndrome (P = .70). Disease burden at the start of bridging chemotherapy, disease burden prior to LDC, and tumor debulking by bridging chemotherapy also did not significantly affect outcomes after CAR T cell therapy in this cohort. In this study, patients receiving ≥2 cycles of bridging chemotherapy had higher rates of infection and lower OS but no difference in CAR-specific toxicity. Clinicians should carefully consider the use of additional cycles of chemotherapy during the bridging period as it delays treatment with CAR T cells and increases the risk of infectious complications. © 2021 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
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22
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Abstract
In 1891, Dr. William B. Coley, an American surgeon, made a compelling observation that immune system can be triggered to shrink tumors. The quest to exploit the power of immunotherapy however was forestalled by an era of chemotherapy that ensued. During World War II, the accidental sinking of a US naval ship led to a group of sailors developing pancytopenia due to poisoning from mustard gas (nitrogen mustard). The observation prompted wide-scale screening of these chemical compounds with cytotoxic potential; further clinical trials led to the first Food and Drug Administration (FDA) approval of a chemotherapy drug, nitrogen mustard. Immunotherapy field took further impetus, not until the last two decades, due to our deeper understanding of the immune system and the cellular and molecular pathways leading to tumor development. Two groundbreaking therapies which have shown great promise in this field involve "taking the breaks off" and "pushing the pedal" of the immune system. These therapies, namely, immune checkpoint inhibitors and adoptive cell therapy, respectively, have been successful in a variety of malignancies, while the former mostly in solid tumors and the latter in hematological malignancies.
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Affiliation(s)
- Ranjit Nair
- Department of Lymphoma and Myeloma, University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
| | - Jason Westin
- Department of Lymphoma and Myeloma, University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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23
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Yagi Y, Kanemasa Y, Sasaki Y, Hayashi Y, Mino M, Kato C, Sakai S, Ohigashi A, Kanbara Y, Morita Y, Tamura T, Atsuta Y, Konuma R, Nakamura S, Wada A, Okuya T, Kageyama A, Murakami D, Nakashima S, Uchibori Y, Onai D, Hamamura A, Nishijima A, Omuro Y, Shingai N, Shimizuguchi T, Toya T, Shimizu H, Najima Y, Kobayashi T, Haraguchi K, Ohashi K, Doki N, Okuyama Y, Shimoyama T. [ Tisagenlecleucel for relapsed/refractory diffuse large B-cell lymphoma: real-world data from single institute experience]. Rinsho Ketsueki 2022; 63:1363-1372. [PMID: 36351641 DOI: 10.11406/rinketsu.63.1363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy has revolutionized the approach to patients with relapsed or refractory diffuse large B-cell lymphoma (r/r DLBCL). This study retrospectively analyzed patients treated with commercially available tisagenlecleucel at our hospital and evaluated its safety and effectiveness. Of the 21 patients evaluated, any grade and grade ≥3 cytokine release syndrome (CRS) occurred in 85.7% and 9.5% of the patients, respectively. A total of 66.7% received tocilizumab and 28.6% received glucocorticoids for the treatment of CRS. The complete response (CR) rate at 3 months was 61.9% (95% confidence interval [CI] 38.4-81.9). After a median follow-up of 6.3 months following CAR-T infusion, the progression-free survival (PFS) and overall survival rates at 6 months were 53.1% (95%CI 28.3-72.7) and 69.2% (95%CI 43.7-84.9), respectively. Severe cytopenia and hypogammaglobulinemia occurred frequently following CAR-T infusion. Eight patients (38.1%) had comorbidities that would have made them ineligible for leukapheresis in the JULIET trial. However, the presence of comorbidities at the time of leukapheresis had no significant effect on the rates of CR, PFS, and adverse events. Tisagenlecleucel for r/r DLBCL in the real-world setting showed high efficacy and manageable safety profile comparable with the pivotal trial.
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Affiliation(s)
- Yu Yagi
- Department of Medical Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Yusuke Kanemasa
- Department of Medical Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Yuki Sasaki
- Department of Medical Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Yudai Hayashi
- Department of Medical Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Mano Mino
- Department of Medical Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Chika Kato
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Satoshi Sakai
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - An Ohigashi
- Department of Medical Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Yasuhiro Kanbara
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Yuka Morita
- Department of Medical Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Taichi Tamura
- Department of Medical Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Yuya Atsuta
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Ryosuke Konuma
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Shohei Nakamura
- Department of Medical Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Atsushi Wada
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Toshihiro Okuya
- Department of Medical Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Akihiko Kageyama
- Department of Medical Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Daisuke Murakami
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Shiori Nakashima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Yusuke Uchibori
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Daishi Onai
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Atsushi Hamamura
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Akihiko Nishijima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Yasushi Omuro
- Department of Medical Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Naoki Shingai
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Takuya Shimizuguchi
- Department of Radiation Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Takashi Toya
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Hiroaki Shimizu
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Yuho Najima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Takeshi Kobayashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Kyoko Haraguchi
- Division of Transfusion and Cell Therapy, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Kazuteru Ohashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Yoshiki Okuyama
- Division of Transfusion and Cell Therapy, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Tatsu Shimoyama
- Department of Medical Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
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Kuboki M, Umezawa Y, Motomura Y, Okada K, Nogami A, Nagao T, Miura O, Yamamoto M. Severe Motor Weakness Due to Disturbance in Peripheral Nerves Following Tisagenlecleucel Treatment. In Vivo 2021; 35:3407-3411. [PMID: 34697176 DOI: 10.21873/invivo.12640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/26/2021] [Accepted: 08/30/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Neurotoxicity is one of the dangerous complications of chimeric antigen receptor (CAR) T-cell therapy, while its pathophysiology remains to be fully understood. Motor weakness not associated with central nervous system (CNS) toxicity has rarely been reported after CAR T-cell therapy. CASE REPORT A 42-year-old female with a refractory diffuse large B-cell lymphoma received tisagenlecleucel (tisa-cel) and developed cytokine release syndrome (CRS) on day 3. She was treated with tocilizumab and methylprednisolone, which resolved CRS promptly. On day 7, motor weakness in lower extremities appeared, and she gradually became unable to walk without showing any other symptoms attributed to CNS disturbances. Whereas dexamethasone and tocilizumab were ineffective, neuropathy improved after high dose chemotherapy followed by autologous stem cell transplantation. Nerve conduction study (NCS) in lower extremities showed a decline in compound muscle action potential amplitude along with worsening of motor weakness, which was restored after improvement of symptoms. Based on symptoms and NCS, her motor weakness was thought to be due to disturbance in peripheral nerves. CONCLUSION This study reports a patient who developed severe motor weakness due to disturbance in peripheral nerves after tisa-cel therapy. Neurotoxicity of non-CNS origin should also be noted in CAR T-cell therapy.
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Affiliation(s)
- Mai Kuboki
- Department of Hematology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshihiro Umezawa
- Department of Hematology, Tokyo Medical and Dental University, Tokyo, Japan;
| | - Yotaro Motomura
- Department of Hematology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Keigo Okada
- Department of Hematology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ayako Nogami
- Department of Hematology, Tokyo Medical and Dental University, Tokyo, Japan.,Department of Clinical Laboratory, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshikage Nagao
- Department of Hematology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Osamu Miura
- Department of Hematology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masahide Yamamoto
- Department of Hematology, Tokyo Medical and Dental University, Tokyo, Japan
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Cunningham K, DiFilippo H, Henes K, Irwin LL, Napier E, Weber E. Tisagenlecleucel Therapy: Nursing Considerations for the Outpatient Setting. Semin Oncol Nurs 2021; 37:151178. [PMID: 34340892 DOI: 10.1016/j.soncn.2021.151178] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 06/07/2021] [Accepted: 06/16/2021] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Tisagenlecleucel is a CD19-directed, genetically modified, autologous T-cell immunotherapy indicated for pediatric and young adult patients with relapsed/refractory B-cell precursor acute lymphoblastic leukemia and for adult patients with relapsed/refractory diffuse large B-cell lymphoma. Treatment with any chimeric antigen receptor (CAR)-T cell therapy is a multistep process in which nurses and nurse practitioners are key to managing patient safety. Managing patients receiving CAR-T cell therapy in the outpatient setting (as Penn does with tisagenlecleucel and lisocabtagene maraleucel) requires an even more complex process. The objective of this manuscript is to provide guidance on the role of nurses in the outpatient administration of tisagenlecleucel therapy and postinfusion care in adult patients with diffuse large B-cell lymphoma. Oncology and apheresis nurses discuss institutional processes and perspectives related to the patient experience with tisagenlecleucel therapy at the Hospital of the University of Pennsylvania. DATA SOURCES Author experience. CONCLUSION Nurses are vital for the success of the patient management processes involved with tisagenlecleucel therapy. Nurses must be thoroughly educated in tisagenlecleucel therapy and adverse event management and be able to effectively communicate all aspects of therapy among the multidisciplinary team of the hospital, the product manufacturer, and patients and families. Establishment of the nurse cellular therapy coordinator at the Hospital of the University of Pennsylvania was advantageous in facilitating effective communication in all these situations. IMPLICATIONS FOR NURSING This encompassing approach to patient management is particularly necessary during administration of tisagenlecleucel therapy and other CAR-T cell therapies that are managed in the outpatient setting.
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Affiliation(s)
- Kathleen Cunningham
- Program Manager, Cell Therapy and Transplant Program, Perelman Center for Advanced Medicine, Hospital of the University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104
| | - Heather DiFilippo
- Nurse Practitioner, Cell Therapy and Transplant Program, Division of Hematology-Oncology and Abramson Cancer Center, University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104
| | - Kelli Henes
- Registered Nurse, Department of Transfusion Medicine, Hospital of the University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104
| | - Leah L Irwin
- Nurse Manager, Apheresis, Infusion, and Donor Services, Department of Transfusion Medicine, Hospital of the University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104
| | - Ellen Napier
- Nurse Practitioner, Abramson Cancer Center, Clinical Research Unit, University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104
| | - Elizabeth Weber
- Cellular Therapy Coordinator, Cell Therapy and Transplant, Perelman Center for Advanced Medicine, Hospital of the University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104.
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26
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Gabelli M, Marks DI, Sharplin K, Lazareva A, Mullanfiroze K, Farish S, Burridge S, Velangi M, Rampling D, Mozayani B, Chiesa R, Lucchini G, Samarasinghe S, Bartram J, Ghorashian S. Graft-versus-host disease induced by tisagenlecleucel in patients after allogeneic stem cell transplantation. Br J Haematol 2021; 195:805-811. [PMID: 34322864 DOI: 10.1111/bjh.17737] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Maria Gabelli
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital for Children, London, UK
| | - David I Marks
- Bone Marrow Transplant Unit, University Hospital, Bristol, UK
| | - Kirsty Sharplin
- Bone Marrow Transplant Unit, University Hospital, Bristol, UK
| | - Arina Lazareva
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital for Children, London, UK
| | - Khushnuma Mullanfiroze
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital for Children, London, UK
| | - Susan Farish
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital for Children, London, UK
| | - Saskia Burridge
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital for Children, London, UK
| | - Mark Velangi
- Department of Haematology, Birmingham Children Hospital, Birmingham, UK
| | - Dyanne Rampling
- Department of Histopathology, Great Ormond Street Hospital for Children, London, UK
| | | | - Robert Chiesa
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital for Children, London, UK
| | - Giovanna Lucchini
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital for Children, London, UK
| | - Sujith Samarasinghe
- Department of Haematology, Great Ormond Street Hospital for Children, London, UK
| | - Jack Bartram
- Department of Haematology, Great Ormond Street Hospital for Children, London, UK
| | - Sara Ghorashian
- Department of Haematology, Great Ormond Street Hospital for Children, London, UK
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27
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Abstract
CD19-targeting chimeric antigen rector (CAR) T-cell products are used for the treatment of relapsed/refractory B-acute lymphoblastic leukemia, diffuse large B-cell lymphoma, and mantle cell lymphoma. The success of CD19-CAR-T cells has led to the investigation of CAR T-cell products targeting different antigens in other hematological malignancies and solid tumors. Clinical laboratories play an important role in the manufacture, distribution, and monitoring of CAR T-cell therapy. Hence, it is important for laboratory professionals to be cognizant of clinicopathologic aspects of CAR T-cell therapy.
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Affiliation(s)
- J Gregory Dolan
- Division of Oncology and Cellular Therapy, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michele E Paessler
- Division of Hematopathology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Susan R Rheingold
- Division of Oncology and Cellular Therapy, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Vinodh Pillai
- Division of Hematopathology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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28
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Moradi-Lakeh M, Yaghoubi M, Seitz P, Javanbakht M, Brock E. Cost-Effectiveness of Tisagenlecleucel in Paediatric Acute Lymphoblastic Leukaemia (pALL) and Adult Diffuse Large B-Cell Lymphoma (DLBCL) in Switzerland. Adv Ther 2021; 38:3427-3443. [PMID: 34021886 DOI: 10.1007/s12325-021-01767-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/28/2021] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The purpose of the present analysis was to explore the cost-effectiveness of tisagenlecleucel in relapsed or refractory (r/r) paediatric acute lymphoblastic leukaemia (pALL) and r/r adult diffuse large B-cell lymphoma (DLBCL) in Switzerland against a range of historical standard-of-care treatments. METHODS Two cost-utility models were constructed for the two licensed indications using similar methodologies but indication-specific data. Clinical efficacy data were based on pooled analyses of clinical trials for tisagenlecleucel (pALL: ELIANA, ENSIGN, B2101J; DLBCL: JULIET, NCT02030834) and published data for comparator treatments. Treatment effects were compared based on matching-adjusted indirect comparison (MAIC) analyses. Four clinical lymphoma and leukaemia experts provided Switzerland-specific input regarding comparators, diagnostic and therapeutic procedures, clinical evidence and costs, which were used to inform the models. The base case analysis reflected the perspective of the Swiss mandatory health insurance system. Deterministic, probabilistic and scenario analyses were carried out to explore the robustness of results. RESULTS The base case analysis resulted in incremental costs of CHF 31,961-CHF 36,419 per quality-adjusted life year (QALY) gained for pALL across the different comparators and CHF 113,179 for DLBCL (1 CHF = 1.09 USD). Incremental costs per life-year gained ranged between CHF 33,906-CHF 97,399 across the two indications. Including productivity gains, tisagenlecleucel was shown to be dominant (more effective and less costly) over all the comparators for pALL and to result in incremental costs per life-year gained of CHF 57,324 for DLBCL. CONCLUSION Using hypothetical willingness-to-pay thresholds of CHF 100,000-150,000 per QALY gained, the present analysis has shown tisagenlecleucel to be a cost-effective treatment option in pALL and DLBCL.
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Affiliation(s)
| | - Mohsen Yaghoubi
- Department of Pharmacy Practice, Mercer University College of Pharmacy, 3001 Mercer University Dr, Atlanta, GA, 30341, USA
- Canada Optimax Access Consulting, 1803-2138 Madison Ave, Burnaby, BC, V5C6T6, Canada
| | - Patrick Seitz
- Novartis Pharma Schweiz AG, Suurstoffi 14, 6343, Rotkreuz, Switzerland
| | - Mehdi Javanbakht
- Optimax Access Ltd., Suite 30 Kenneth Dibben House, Enterprise Road, Southampton Science Park, Chilworth, Southampton, SO16 7NS, UK
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29
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Maillet D, Belin C, Moroni C, Cuzzubbo S, Ursu R, Sirven-Villaros L, Di Blasi R, Thieblemont C, Carpentier AF. Evaluation of mid-term (6-12 months) neurotoxicity in B-cell lymphoma patients treated with CAR T-cells: a prospective cohort study. Neuro Oncol 2021; 23:1569-1575. [PMID: 33822183 DOI: 10.1093/neuonc/noab077] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND CAR T-cells are profoundly changing the standard of care in B-cell malignancies. This new therapeutic class induces a significant number of acute neurotoxicity, but data regarding mid and long-term neurological safety are scarce. We evaluated mid-term neurological safety, with special emphasis on cognitive functions, in a series of adults treated with CAR T-cells. METHODS Patients treated in a single centre with CD19-targeted CAR T-cells for a relapsing B-cell lymphoma were prospectively followed-up by neurologists. Before CAR T-cells infusion, all patients underwent neurological examinations with neuropsychological testing, and filled out questionnaires assessing anxiety, depression and cognitive complains. Patients surviving without tumour progression were re-evaluated similarly, six to 12 months later. RESULTS In this prospective cohort of 56 consecutive adult patients treated with CAR T-cells, 27 were eligible for mid-term evaluation (median time 7.6 months). Twelve patients developed an acute and reversible neurotoxicity with median duration time of 5.5 days. In all patients, neurological examination on mid-term evaluation was similar to baseline. In self-assessment questionnaires, 63% of patients reported clinically meaningful anxiety, depression or cognitive difficulties at baseline, a number reduced to 44% at time of mid-term evaluation. On cognitive assessments, no significant deterioration was found when compared to baseline, in any cognitive functions assessed (verbal and visual memory, executive functions, language and praxis), even in patients who developed acute neurotoxicity. CONCLUSION In this cohort of patients treated with CD19-targeted CAR-T cells , we found no evidence for neurological or cognitive toxicity, 6 and 12 months after treatment.
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Affiliation(s)
- Didier Maillet
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Louis, Service de Neurologie, Paris, France
| | - Catherine Belin
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Louis, Service de Neurologie, Paris, France
| | - Christine Moroni
- Université de Lille, ULR 4072 - PSITEC - Psychologie : Interactions, Temps, Emotions, Cognition, Lille, France
| | - Stefania Cuzzubbo
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Louis, Service de Neurologie, Paris, France
| | - Renata Ursu
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Louis, Service de Neurologie, Paris, France
| | - Lila Sirven-Villaros
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Louis, Service de Neurologie, Paris, France.,Université de Paris, Paris Diderot, Paris, France
| | - Roberta Di Blasi
- Université de Paris, Paris Diderot, Paris, France.,Service d'Hémato-Oncologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Catherine Thieblemont
- Université de Paris, Paris Diderot, Paris, France.,Service d'Hémato-Oncologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Antoine F Carpentier
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Louis, Service de Neurologie, Paris, France.,Université de Paris, Paris Diderot, Paris, France
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30
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Wakase S, Teshima T, Zhang J, Ma Q, Fujita T, Yang H, Chai X, Qi CZ, Liu Q, Wu EQ, Igarashi A. Cost Effectiveness Analysis of Tisagenlecleucel for the Treatment of Adult Patients with Relapsed or Refractory Diffuse Large B Cell Lymphoma in Japan. Transplant Cell Ther 2021; 27:506.e1-506.e10. [PMID: 33823168 DOI: 10.1016/j.jtct.2021.03.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/04/2021] [Accepted: 03/02/2021] [Indexed: 12/31/2022]
Abstract
There are limited treatment options and substantial unmet needs for adult patients with relapsed or refractory diffuse large B cell lymphoma (r/r DLBCL) in Japan. In 2019, tisagenlecleucel, a CD19-directed chimeric antigen receptor T cell therapy, was approved for r/r DLBCL in Japan. The efficacy and safety of tisagenlecleucel were demonstrated in the pivotal phase II single-arm JULIET trial. The objective of the current study was to assess the cost-effectiveness of tisagenlecleucel treatment strategy versus current standard of care (salvage chemotherapy treatment strategy) for the treatment of patients with r/r DLBCL in Japan. A three-state partitioned survival model was constructed from a Japanese public healthcare payer's perspective, with the following three health states: progression-free survival, progressive/relapsed disease, and death. Because the tisagenlecleucel arm included patients who did or did not receive the infusion, a decision-tree structure was used to partition patients based on their infusion status. Treatment efficacy and costs were based on tisagenlecleucel-infused patients for those who received the infusion; for non-infused patients, they were based on standard salvage chemotherapy. The efficacy inputs for tisagenlecleucel-infused patients and salvage chemotherapy were based on observed data in the JULIET trial and the international SCHOLAR-1 meta-analysis, respectively, before year 3. Afterward, all patients were assumed to have no further progression and to incur the mortality risk of long-term DLBCL survivors. The base case analysis explored a lifetime horizon (44 years), with costs and effectiveness discounted 2.0% annually, and it used a monthly model cycle. Direct costs were considered in the base case, composed of pretreatment costs, treatment costs, adverse events management costs, follow-up costs before progression, subsequent SCT costs, post-progression costs, and terminal care costs. Total incremental costs, life years (LYs), and quality-adjusted life years (QALYs) were compared for tisagenlecleucel versus salvage chemotherapy. The incremental cost-effectiveness ratio (ICER) was estimated as the costs per QALY gained, and a threshold of ¥7.5 million was used to assess whether tisagenlecleucel is cost effective. Deterministic and probabilistic sensitivity analyses were performed. The total LYs (discounted) for tisagenlecleucel and salvage chemotherapy were 7.24 and 4.35 years, respectively; the corresponding QALYs were 5.42 and 2.57 years, respectively. The discounted incremental LYs and QALYs comparing tisagenlecleucel to salvage chemotherapy were estimated as 2.89 and 2.85 years, respectively. Over a lifetime horizon, the model estimated that tisagenlecleucel had a total incremental cost of ¥15,590,335 (discounted) versus salvage chemotherapy. Tisagenlecleucel was associated with an ICER of ¥5,476,496 per QALY gained compared to salvage chemotherapy. Extensive sensitivity analyses supported the base-case findings. Tisagenlecleucel is a cost-effective treatment strategy for r/r DLBCL compared to salvage chemotherapy treatment strategy from a Japanese public healthcare payer's perspective.
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31
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Abstract
BACKGROUND Two commercial chimeric antigen receptor (CAR) T cell products, axicabtagene-ciloleucel (Yescarta®) and tisagenlecleucel (Kymriah®), are registered for the treatment of B cell neoplasia, for which an increased supply of CAR T cell products is required. PROBLEM The production of patient-specific CAR T cells as advanced therapy medicinal products (ATMPs) poses considerable challenges with respect to logistics, regulation, and manufacturing. METHOD Review of the CAR T cell manufacturing process and the regulatory network, the current challenges, and future development capabilities of CAR T cells for adoptive immunotherapy. RESULTS CAR T cells are manufactured under individualized, laborious, good manufacturing practice-conforming processes in decentralized or in specialized centers. Starting from the patient's leukapheresis product, T cells are genetically engineered ex vivo with a CAR, amplified, and after extensive quality control re-applied to the patient. Most CAR T cell products are manufactured in a manual or semi-automated process; fully automated, supervised, and closed systems are increasingly applied to meet the need for a growing number of CAR T cell products. In this setting, research aims at providing allogeneic CAR T cell products or non-T cells such as natural killer cells for broad applications. CONCLUSION The significance of CAR T cells in adoptive immunotherapy is continuously growing. As individualized cell products, manufacturing requires highly efficient processes under the control of harmonized protocols and regulations so as to ensure the quality of the ATMP in view of increasing demand and to develop new fields in therapy.
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Affiliation(s)
- Ulrike Köhl
- Fraunhofer-Institut für Zelltherapie und Immunologie (IZI), Leipzig, Deutschland.,Institut für Klinische Immunologie, Universität Leipzig, Leipzig, Deutschland.,Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Hinrich Abken
- Regensburger Centrum für Interventionelle Immunologie (RCI), Abteilung für Gen-Immuntherapie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
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32
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Wang XJ, Wang YH, Li SCT, Gkitzia C, Lim ST, Koh LP, Lim FLWI, Hwang WYK. Cost-effectiveness and budget impact analyses of tisagenlecleucel in adult patients with relapsed or refractory diffuse large B-cell lymphoma from Singapore's private insurance payer's perspective. J Med Econ 2021; 24:637-653. [PMID: 33904359 DOI: 10.1080/13696998.2021.1922066] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients experiencing relapsed or refractory diffuse large B-cell lymphoma (r/r DLBCL) have limited treatment options and poor prognosis. Tisagenlecleucel (TIS) has shown improved clinical outcomes, but at a high upfront cost. Singapore has a multi-payer healthcare system where private insurance is one of the major payers. This study evaluated the cost-effectiveness and budget impact of TIS against salvage chemotherapy regimen (SCR) for treating r/r DLBCL patients who have failed ≥2 lines of systemic therapy from Singapore's private insurance payer's perspective. METHODS Over a life-time horizon, a partitioned survival model with three health-states was developed to evaluate the cost-effectiveness of TIS vs. SCR with or without hematopoietic stem cell transplantation (HSCT). Efficacy inputs for TIS and SCR were based on 43 months of observation data from pooled JULIET and UPenn trials, and CORAL extension studies respectively. Direct costs for pre-treatment, treatment, adverse events, follow-up, subsequent-HSCT, relapse, and terminal care were included. Incremental cost-effectiveness ratios (ICERs) were calculated as the total incremental costs per quality-adjusted life-year (QALY) gained. Additionally, the financial implication of introducing TIS in Singapore from a private payer's perspective was analyzed, comparing the current treatment pathway (without TIS) with a future scenario (with TIS) over 5 years. RESULTS Compared with SCR, TIS was the dominant option, with cost savings of S$8,477 alongside an additional gain of 2.78 QALYs in privately insured patients who shifted from private to public hospitals for TIS treatment. Scenario analyses for patients starting in public hospitals show ICERs of S$99,623 (no subsidy) and S$133,261 (50% subsidy for SCR treatment, no subsidy for TIS), supporting the base case. The projected annual budget impact ranges from S$850,000 to S$3.4 million during the first 5 years. CONCLUSIONS TIS for treating r/r DLBCL patients who have failed ≥2 lines of systemic therapies, is likely to be cost effective with limited budget impact.
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Affiliation(s)
| | - Yi-Ho Wang
- Novartis Singapore Pte Ltd., Singapore, Singapore
| | | | | | - Soon Thye Lim
- National Cancer Centre Singapore, Singapore, Singapore
| | - Liang Piu Koh
- National University Cancer Institute, Singapore, Singapore
| | | | - William Ying Khee Hwang
- National University Cancer Institute, Singapore, Singapore
- Singapore General Hospital, Singapore, Singapore
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33
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Wakase S, Teshima T, Zhang J, Ma Q, Watanabe Y, Yang H, Qi CZ, Chai X, Xie Y, Wu EQ, Igarashi A. Cost-Effectiveness Analysis of Tisagenlecleucel for the Treatment of Pediatric and Young Adult Patients with Relapsed or Refractory B Cell Acute Lymphoblastic Leukemia in Japan. Transplant Cell Ther 2020; 27:241.e1-241.e11. [PMID: 33781519 DOI: 10.1016/j.jtct.2020.12.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
Until recently, treatment options were relatively limited for children and young adults with relapsed or refractory (r/r) acute lymphoblastic leukemia (ALL). Tisagenlecleucel is a chimeric antigen receptor T cell (CAR-T) immunotherapy with promising efficacy and manageable safety that was approved in Japan in 2019 for the treatment of CD19-positive r/r B cell ALL (B-ALL). However, there is no publication assessing the cost-effectiveness of CAR-T in Japan. The objective of this study was to assess the cost-effectiveness of a tisagenlecleucel treatment strategy compared to a blinatumomab treatment strategy and a clofarabine combination treatment strategy (i.e., clofarabine + cyclophosphamide + etoposide) in Japan for pediatric and young adult patients up to 25 years of age with r/r B-ALL. A partitioned survival model with a lifetime horizon and monthly cycle was constructed from a Japanese public healthcare payer's perspective. Patients were distributed across the following partitioned health states: event-free survival (EFS), progressive disease, and death, which were informed by the EFS and overall survival (OS) data of respective clinical trials before year 5. For the tisagenlecleucel arm, a decision-tree structure was used to partition patients based on the infusion status; those who discontinued prior to receiving infusion were assigned efficacy and cost inputs of blinatumomab and those who received infusion were assigned efficacy and costs inputs based on tisagenlecleucel-infused patients. As trial data for blinatumomab and clofarabine ended before year 5, matching-adjusted indirect comparisons were used to extrapolate OS between the end of trial observation and up to year 5. All surviving patients followed the mortality risk of long-term ALL survivors without additional risk of disease relapse after year 5, regardless of initial treatment strategies. The model accounted for pretreatment costs, treatment costs, adverse event costs, follow-up costs, subsequent allogeneic hematopoietic stem cell transplantation costs, and terminal care costs. Incremental cost-effectiveness ratios (ICERs) per life-years (LYs) gained and ICERs per quality-adjusted life-years (QALYs) gained were evaluated using a 2% discount rate, and a threshold of ¥7.5 million was used to assess cost-effectiveness. Deterministic and probabilistic sensitivity analyses were performed. The total LYs (discounted) for tisagenlecleucel, blinatumomab, and clofarabine combination treatment strategies were 13.3, 4.0, and 2.7 years, respectively; the corresponding QALYs were 11.6, 3.1, and 2.1 years, respectively. The ICERs per QALY gained for tisagenlecleucel were ¥2,035,071 versus blinatumomab and ¥2,644,702 versus clofarabine combination therapy. Extensive sensitivity analyses supported the findings. Tisagenlecleucel is a cost-effective treatment strategy for pediatric and young adult patients with r/r B-ALL from a Japanese public healthcare payer's perspective.
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Affiliation(s)
| | - Takanori Teshima
- Department of Hematology, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Jie Zhang
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Qiufei Ma
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | | | | | | | | | - Eric Q Wu
- Analysis Group, Inc., Boston, Massachusetts
| | - Ataru Igarashi
- Yokohama City University School of Medicine, Yokohama, Japan; Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
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Cher BP, Gan KY, Aziz MIA, Lin L, Hwang WYK, Poon LM, Ng K. Cost utility analysis of tisagenlecleucel vs salvage chemotherapy in the treatment of relapsed/refractory diffuse large B-cell lymphoma from Singapore's healthcare system perspective. J Med Econ 2020; 23:1321-1329. [PMID: 32780608 DOI: 10.1080/13696998.2020.1808981] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Patients with relapsed or refractory diffuse large B-cell lymphoma (r/r DLBCL) have limited treatment options and poor prognoses. Tisagenlecleucel, a chimeric antigen receptor (CAR) T-cell therapy has shown early promise in improving survival outcomes, but at a high upfront cost. This study evaluated the cost-effectiveness of tisagenlecleucel versus salvage chemotherapy for treating patients with r/r DLBCL who have failed at least 2 lines of systemic therapies. METHODS A hybrid decision tree and three-state partitioned survival model (progression-free (PF), progressive disease and death) was developed from the Singapore healthcare payer perspective. Survival curves from JULIET trial and CORAL-1 extension study were extrapolated beyond trial period over a 15-year time horizon to estimate the underlying progression-free survival and overall survival parametric distributions for both arms. Health state utilities were retrieved from the literature, and direct costs were sourced from public healthcare institutions in Singapore. One-way probabilistic sensitivity analyses and scenario analyses were conducted to explore the impact of uncertainties and assumptions on cost-effectiveness results. RESULTS Compared with salvage chemotherapy, tisagenlecleucel was associated with a base-case incremental cost-effectiveness ratio (ICER) US$508,530 (S$686,516) per quality adjusted life year (QALY) gained and US$320,200 (S$432,269) per life year (LY) gained. One-way sensitivity analysis showed the ICER was most sensitive to time horizon, PF utility and cost of tisagenlecleucel. Scenario analyses confirmed that the ICERs remained high under favorable assumptions and substantial price reduction was required to reduce the ICER. CONCLUSIONS Our analysis showed tisagenlecleucel use in r/r DLBCL patients who failed at least 2 prior lines of systemic therapies was associated with exceedingly high ICER, which is unlikely to represent good use of healthcare resources. Comparative clinical evidence from the ongoing trials might provide more insight into future evaluations.
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Affiliation(s)
- Boon Piang Cher
- Agency for Care Effectiveness, Ministry of Health, Singapore, Singapore
| | - Kar Yee Gan
- Agency for Care Effectiveness, Ministry of Health, Singapore, Singapore
| | | | - Liang Lin
- Agency for Care Effectiveness, Ministry of Health, Singapore, Singapore
| | - William Ying Khee Hwang
- National Cancer Centre Singapore, Singapore, Singapore
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Li Mei Poon
- Department of Haematology-Oncology, National University Hospital Singapore, Singapore, Singapore
| | - Kwong Ng
- Agency for Care Effectiveness, Ministry of Health, Singapore, Singapore
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Abstract
Chimeric antigen receptor-engineered T (CAR-T) cell immunotherapy has been successful in treating many types of hematological malignancies. CAR-T therapy, however, has been associated with toxicities, including cytokine release syndrome (CRS) as well as immune effector cell-associated neurotoxicity syndrome (ICANS). ICANS presentation is variable, largely reversible, and manifests with encephalopathy and focal neurologic deficits. Treatment strategies largely are supportive. ICANS pathophysiology likely is related to that of CRS. Preclinical studies and clinical experience have shed light on the driving forces of ICANS and have yielded new strategies to mitigate ICANS occurrence.
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Affiliation(s)
- Michael W Ruff
- T Cell Engineering, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Department of Neurology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Elizabeth L Siegler
- T Cell Engineering, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Division of Hematology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Saad S Kenderian
- T Cell Engineering, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Division of Hematology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Department of Molecular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Department of Immunology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Khalife R, Montroy J, Grigor EJM, Fergusson DA, Atkins H, Seftel M, Presseau J, Thavorn K, Holt RA, Hay K, Lalu MM, Kekre N. Building Canadian capacity for CAR-T cells in relapsed/refractory acute lymphoblastic leukaemia: a retrospective cohort study. Br J Haematol 2020; 191:e14-e19. [PMID: 32688454 DOI: 10.1111/bjh.16940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 06/11/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Roy Khalife
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Joshua Montroy
- Clinical Epidemiology Program, Ottawa Hospital Research Institiute, Ottawa, Ontario, Canada
| | - Emma J M Grigor
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Blood and Marrow Transplant Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Pubic Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Harold Atkins
- Blood and Marrow Transplant Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Cancer Therapeutic Program, Ottawa Hospital Research Institute, Ontario, Ottawa, Canada
| | - Matthew Seftel
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institiute, Ottawa, Ontario, Canada.,School of Epidemiology and Pubic Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institiute, Ottawa, Ontario, Canada.,School of Epidemiology and Pubic Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Robert A Holt
- Michael Smith Genome Sciences Centre, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Kevin Hay
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Manoj M Lalu
- Clinical Epidemiology Program, Ottawa Hospital Research Institiute, Ottawa, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ontario, Ottawa, Canada
| | - Natasha Kekre
- Clinical Epidemiology Program, Ottawa Hospital Research Institiute, Ottawa, Ontario, Canada.,Blood and Marrow Transplant Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Imai C. [Current status of cancer immunotherapy for relapsed/refractory acute lymphoblastic leukemia in children and adolescents in Japan]. Rinsho Ketsueki 2020; 61:673-681. [PMID: 32624542 DOI: 10.11406/rinketsu.61.673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Several novel therapeutics that employ immunological mechanisms have been introduced in recent years for the treatment of hematological malignancies. To date, very few drugs have been introduced for acute lymphoblastic leukemia (ALL). Nonetheless, three novel agents have been approved recently in the US, Europe, Australia, and Japan: blinatumomab, which kills CD19-positive leukemia cells via cytotoxic activity of the patient's autologous T cells; inotuzumab ozogamicin, which delivers the anti-cancer antibiotic calicheamicin via CD22 internalization after antibody binding; and tisagenlecleucel, which uses patient's T cells via anti-CD19 chimeric antigen receptors. Aggressive multi-agent chemotherapy followed by allogeneic hematopoietic cell transplantation has been the only curative strategy for relapsed or refractory ALL. However, treatment strategies for such patients are about to change dramatically. In this article, I review the clinical development of the new therapeutics and discuss their roles in modern therapy for ALL in children and adolescents. An approach for treatment selection has not yet been established. Therefore, it is important to understand the advantages and disadvantages of each treatment for choosing a treatment strategy for each individual.
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Affiliation(s)
- Chihaya Imai
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences
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Zhang J, Li J, Ma Q, Yang H, Signorovitch J, Wu E. A Review of Two Regulatory Approved Anti-CD19 CAR T-Cell Therapies in Diffuse Large B-Cell Lymphoma: Why Are Indirect Treatment Comparisons Not Feasible? Adv Ther 2020; 37:3040-3058. [PMID: 32524498 PMCID: PMC7467403 DOI: 10.1007/s12325-020-01397-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Indexed: 12/28/2022]
Abstract
Anti-CD19 chimeric antigen receptor (CAR) T-cell therapies can be effective for diffuse large B-cell lymphoma (DLBCL), a cancer with limited treatment options and poor outcomes, particularly for patients with relapsed or refractory (r/r) disease. Axicabtagene ciloleucel (axi-cel) and tisagenlecleucel (tisa-cel) are CAR T-cell therapies approved by regulatory bodies for certain patients with r/r DLBCL on the basis of demonstrated treatment effects in their pivotal single-arm trials, ZUMA-1 and JULIET, respectively. In the absence of head-to-head trials, the question of whether a valid indirect treatment comparison (ITC) between axi-cel and tisa-cel could be performed using existing evidence is of interest to patients, physicians, payers, and other stakeholders. This article addresses that question by summarizing the current evidence from clinical trials and real-world studies and discussing the challenges and limitations of potential analytical approaches associated with an ITC. Two ITC approaches attempting to adjust for cross-trial heterogeneity between ZUMA-1 and JULIET, matching-adjusted indirect comparison and regression-prediction model analysis, were evaluated. After evaluating the current clinical trial data and real-world evidence, and present and prior ITC analyses of axi-cel and tisa-cel, the authors conclude that a valid comparative analysis is not currently feasible. The substantial differences (e.g., timing of leukapheresis and enrollment, use of bridging chemotherapy [90% in JULIET vs. 0% in ZUMA-1], lymphodepleting regimens) between the two trials' designs and patient populations preclude a robust and reliable ITC. No other approaches are able to account for such differences. The current real-world data are still too immature to be used for ITCs. Thus, drawing conclusions from such ITCs should be avoided to prevent misinforming treatment choices or limiting patient access to effective treatment options. Additional data from ongoing or future real-world studies with appropriate statistical analyses are needed to provide insights into the comparative effectiveness and safety of these two treatments.
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Affiliation(s)
- Jie Zhang
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Qiufei Ma
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | | | - Eric Wu
- Analysis Group, Inc., Boston, MA, USA
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Goto H, Makita S, Kato K, Tokushige K, Fujita T, Akashi K, Izutsu K, Teshima T. Efficacy and safety of tisagenlecleucel in Japanese adult patients with relapsed/refractory diffuse large B-cell lymphoma. Int J Clin Oncol 2020; 25:1736-1743. [PMID: 32448949 PMCID: PMC7441082 DOI: 10.1007/s10147-020-01699-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 05/01/2020] [Indexed: 12/02/2022]
Abstract
Background Tisagenlecleucel demonstrated a high rate of durable response in adult patients with relapsed/refractory (r/r) diffuse large B-cell lymphoma (DLBCL) in the pivotal global phase 2 JULIET study. Here, we report the efficacy and safety of tisagenlecleucel in the Japanese subgroup. Methods JULIET (NCT02445248) is a single-arm, open-label, multicenter, phase 2 study involving adult patients with r/r DLBCL who either relapsed after or were ineligible for autologous stem cell transplant. Primary endpoint was best overall response rate (ORR; complete response [CR] + partial response [PR]) as judged by an independent review committee. Results In Japan, of 17 patients enrolled, 9 were infused with tisagenlecleucel and completed ≥ 3 months of follow-up. Best ORR was 77.8% (7/9; 95% confidence interval, 40.0–97.2), with 5 patients (55.6%) in CR and 2 (22.2%) in PR. Cytokine release syndrome (CRS) occurred in 6 patients (66.7%), with grade 3 CRS in 2 patients (Penn grading scale). Two patients received tocilizumab. Two deaths (22.2%) occurred more than 30 days after tisagenlecleucel infusion due to disease progression, neither of which were related to tisagenlecleucel. Conclusion Tisagenlecleucel showed a high best ORR with a manageable safety profile, thus offering a new treatment option in selected Japanese patients with r/r DLBCL.
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Affiliation(s)
- Hideki Goto
- Department of Hematology, Graduate School of Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan.
| | - Shinichi Makita
- Department of Hematology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Koji Kato
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | | | - Taizo Fujita
- Novartis Pharma K.K., Toranomon Minato-ku, Tokyo, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Koji Izutsu
- Department of Hematology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Takanori Teshima
- Department of Hematology, Graduate School of Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
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40
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Ittershagen S, Ericson S, Eldjerou L, Shojaee A, Bleickardt E, Patel M, Taran T, Anak O, Hall C, Leung M, Roccoberton D, Salmon F, Fuchs M, Romanov V, Lebwohl D. Industry's Giant Leap Into Cellular Therapy: Catalyzing Chimeric Antigen Receptor T Cell (CAR-T) Immunotherapy. Curr Hematol Malig Rep 2019; 14:47-55. [PMID: 30666506 DOI: 10.1007/s11899-019-0498-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE OF REVIEW We describe the significant technological leap from bench to bedside that was achieved through a strong academic-industry collaboration between dedicated clinicians and researchers at the University of Pennsylvania, the Children's Hospital of Philadelphia, and Novartis to commercialize the chimeric antigen receptor T cell (CAR-T) therapy tisagenlecleucel (CTL019; Kymriah®; Novartis Pharma AG, Basel, Switzerland). RECENT FINDINGS Tisagenlecleucel was the first CAR-T therapy and the first gene therapy to receive US Food and Drug Administration approval in 2017, with an initial indication for pediatric and young adult patients with relapsed or refractory (r/r) acute lymphoblastic leukemia, followed by approval in May 2018 for a second indication in adult patients with r/r diffuse large B cell lymphoma. Subsequent approvals in the European Union, Switzerland, and Canada soon followed. The tisagenlecleucel success story represents the development and commercialization of a first-of-its-kind personalized cellular therapy with a manufacturing process that supports commercial production and ongoing global clinical trials in a growing number of countries.
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41
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Abstract
The approval of tisagenlecleucel in B-lineage acute lymphoblastic leukemias in 2017 in the USA and in 2018 in Europe not only opened new hopes but forced to rethink the hospital organizations around this innovation. Indeed, if these treatments are very effective in the short term, the complex logistics required imply high quality inter-center and intra-center collaboration. Hematology, intensive care unit, apheresis, neurology, cell therapy and biology laboratories, and radiology services must therefore act in a coordinated manner. A specialized monitoring for the mid and long term must also be implemented. Many questions remain concerning the profile of eligible patients, the short and long-term safety, the longer-term efficacy, improving the persistence of CAR-T cells, controlling the risk of tumor escape, the use of allogenic CAR-T cells, or the application of this concept to T-cell ALL. The precise evaluation of the involved costs and the cost-effectiveness of these therapies will also be the subject of future studies.
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Affiliation(s)
- Audrey Grain
- AP-HP, université de Paris, hôpital universitaire Robert-Debré, service d'hémato-immunologie pédiatrique, 48, boulevard Serurier, 75019 Paris, France.
| | - Marie-Emilie Dourthe
- AP-HP, université de Paris, hôpital universitaire Robert-Debré, service d'hémato-immunologie pédiatrique, 48, boulevard Serurier, 75019 Paris, France
| | - André Baruchel
- AP-HP, université de Paris, hôpital universitaire Robert-Debré, service d'hémato-immunologie pédiatrique, 48, boulevard Serurier, 75019 Paris, France
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42
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Hiramatsu H, Adachi S, Umeda K, Kato I, Eldjerou L, Agostinho AC, Natsume K, Tokushige K, Watanabe Y, Grupp SA. Efficacy and safety of tisagenlecleucel in Japanese pediatric and young adult patients with relapsed/refractory B cell acute lymphoblastic leukemia. Int J Hematol 2019; 111:303-310. [PMID: 31709501 DOI: 10.1007/s12185-019-02771-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 10/24/2019] [Accepted: 10/29/2019] [Indexed: 10/25/2022]
Abstract
Tisagenlecleucel is an autologous T cell genetically modified ex vivo using a lentiviral vector encoding an anti-CD19 chimeric antigen receptor. Here, we present the efficacy and safety of tisagenlecleucel in a subgroup of Japanese patients with relapsed/refractory (r/r) B-cell acute lymphoblastic leukemia (ALL). ELIANA was a single-arm, open-label, multicenter, phase 2 study. Patients were aged ≥ 3 years at screening to ≤ 21 years at the time of diagnosis, and had ≥ 5% lymphoblasts in bone marrow at screening. Primary endpoint was overall remission rate [ORR; complete remission (CR) + CR with incomplete blood recovery (CRi)] within 3 months after infusion. As of April 13, 2018, eight patients were enrolled and six had been infused. ORR was 66.7% (95% confidence interval 22.3-95.7); three patients achieved CR and one patient had CRi. All patients with CR/CRi were negative for minimal residual disease. One patient had CR/CRi lasting 19.5 + months. Cytokine release syndrome (CRS) and neurological events occurred in 83% and 17% of patients, respectively. CRS resolved with anti-cytokine therapy and supportive care. Two deaths occurred due to disease progression. No cases of cerebral edema were observed. Tisagenlecleucel produced high remission rates and durable responses offering a new treatment option for Japanese pediatric and young adults with r/r B-ALL.
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Affiliation(s)
- Hidefumi Hiramatsu
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Souichi Adachi
- Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Katsutsugu Umeda
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Itaru Kato
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | | | | | | | | | - Stephan A Grupp
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
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Abstract
OBJECTIVE To discuss the mechanism of action and nursing care of adults receiving chimeric antigen receptor (CAR) T-cell therapy. DATA SOURCE Peer reviewed articles and pharmaceutical drug labels. CONCLUSION CAR T-cell therapy is among the most exciting therapies in the evolution of cancer treatment. The efficacy of research with CAR T-cell therapy has shown promising results in hematologic malignancies as well as in solid tumors. IMPLICATIONS FOR NURSING PRACTICE Understanding the complexity of care for these patients from the bedside to the outpatient setting is vital for their survival and quality of care.
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Affiliation(s)
| | - Brittney Baer
- Hematology-Oncology Program, Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Rhea Micci Simons
- Hematology-Oncology Program, Vanderbilt-Ingram Cancer Center, Nashville, TN
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Cope S, Ayers D, Zhang J, Batt K, Jansen JP. Integrating expert opinion with clinical trial data to extrapolate long-term survival: a case study of CAR-T therapy for children and young adults with relapsed or refractory acute lymphoblastic leukemia. BMC Med Res Methodol 2019; 19:182. [PMID: 31477025 PMCID: PMC6721254 DOI: 10.1186/s12874-019-0823-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 08/15/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Long-term clinical outcomes are necessary to assess the cost-effectiveness of new treatments over a lifetime horizon. Without long-term clinical trial data, current practice to extrapolate survival beyond the trial period involves fitting alternative parametric models to the observed survival. Choosing the most appropriate model is based on how well each model fits to the observed data. Supplementing trial data with feedback from experts may improve the plausibility of survival extrapolations. We demonstrate the feasibility of formally integrating long-term survival estimates from experts with empirical clinical trial data to provide more credible extrapolated survival curves. METHODS The case study involved relapsed or refractory B-cell pediatric and young adult acute lymphoblastic leukemia (r/r pALL) regarding long-term survival for tisagenlecleucel (chimeric antigen receptor T-cell [CAR-T]) with evidence from the phase II ELIANA trial. Seven pediatric oncologists and hematologists experienced with CAR-T therapies were recruited. Relevant evidence regarding r/r pALL and tisagenlecleucel provided a common basis for expert judgments. Survival rates and related uncertainty at 2, 3, 4, and 5 years were elicited from experts using a web-based application adapted from Sheffield Elicitation Framework. Estimates from each expert were combined with observed data using time-to-event parametric models that accounted for experts' uncertainty, producing an overall distribution of survival over time. These results were validated based on longer term follow-up (median duration 24.2 months) from ELIANA following the elicitation. RESULTS Extrapolated survival curves based on ELIANA trial without expert information were highly uncertain, differing substantially depending on the model choice. Survival estimates between 2 to 5 years from individual experts varied with a fair amount of uncertainty. However, incorporating expert estimates improved the precision in the extrapolated survival curves. Predictions from a Gompertz model, which experts believed was most appropriate, suggested that more than half of the ELIANA patients treated with tisagenlecleucel will survive up to 5 years. Expert estimates at 24 months were validated by longer follow-up. CONCLUSIONS This study provides an example of how expert opinion can be elicited and synthesized with observed survival data using a transparent and formal procedure, capturing expert uncertainty, and ensuring projected long-term survival is clinically plausible.
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Affiliation(s)
- Shannon Cope
- Precision Xtract, 1505 West 2nd Avenue, Suite 300, Vancouver, BC V6H 3Y4 Canada
| | - Dieter Ayers
- Precision Xtract, 1505 West 2nd Avenue, Suite 300, Vancouver, BC V6H 3Y4 Canada
| | - Jie Zhang
- Global Oncology Strategy and Business Dev, Novartis Pharmaceuticals Corporation, 1 Health Plaza, East Hanover, NJ 07936 USA
| | - Katharine Batt
- Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 USA
| | - Jeroen P. Jansen
- Precision Xtract, 555 12th Street, Suite 250, Oakland, CA 94607 USA
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45
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Abstract
OBJECTIVE To discuss current recommendations and resources for nurses to ensure they advocate for patients with cytokine release syndrome (CRS). DATA SOURCES A literature search using key terms: cytokine release syndrome, neurotoxicity, CAR T, adverse events. CONCLUSION Chimeric antigen receptor (CAR) T-cell immunotherapy is a growing and rapidly changing field of research. Prompt recognition and management of the side effects of CAR T-cell therapy is pivotal to the safe outcomes of patients. As patients are treated with these novel therapies, additional recommendations and standards for treating CRS and neurotoxicity will occur. IMPLICATION FOR NURSING PRACTICE Nursing plays a pivotal role in the CAR T patients' treatment course because they are the first line of defense in the care of these patients. Providers and patients both rely on nursing knowledge and training to recognize symptoms of CRS and neurotoxicity. With the early recognition of the signs and symptoms of CRS and neurotoxicity, nursing will help improve the outcomes of the patients receiving CAR T-cell therapy.
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Affiliation(s)
- Brittney Baer
- Hematology-Oncology Program, Vanderbilt-Ingram Cancer Center, Nashville, TN.
| | | | - Rhea Micci Simons
- Hematology-Oncology Program, Vanderbilt-Ingram Cancer Center, Nashville, TN
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Abstract
INTRODUCTION Cure rates for pediatric and young adult patients with refractory or recurrently relapsed acute lymphoblastic leukemia (ALL) are dismal. Survival from time of relapse is typically measured in weeks to months, and standard chemotherapy and currently approved targeted therapy achieve remission in less than a third of affected patients. To date, the only definitive curative therapy has been allogeneic hematopoietic stem cell transplant (HSCT). Advances in immunotherapy, with the introduction of chimeric antigen receptor T-cell therapies and the development of tisagenlecleucel, have changed the landscape. Areas covered: This review will describe the pharmacology of tisagenlecleucel and summarize the clinical evidence for its use in the treatment of multiple-relapsed or refractory B-cell ALL (B-ALL). Also discussed are other immunotherapies for B-ALL as well as the most commonly-encountered toxicities and corresponding management strategies. Expert commentary: Early phase trials indicate that tisagenlecleucel significantly improves survival for patients with B-ALL that is refractory or in second or later relapse. In responding patients, remissions have been reported on the order of years, and thus, tisagenlecleucel may herald a dramatic shift in the treatment paradigm of this largely fatal disease.
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Affiliation(s)
- Allison Barz Leahy
- a Divisions of Pediatric Hematology and Oncology , Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine , Philadelphia , PA , USA
| | - Caitlin W Elgarten
- a Divisions of Pediatric Hematology and Oncology , Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine , Philadelphia , PA , USA
| | - Stephan A Grupp
- a Divisions of Pediatric Hematology and Oncology , Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine , Philadelphia , PA , USA
| | - Shannon L Maude
- a Divisions of Pediatric Hematology and Oncology , Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine , Philadelphia , PA , USA
| | - David T Teachey
- a Divisions of Pediatric Hematology and Oncology , Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine , Philadelphia , PA , USA
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47
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Dushenkov A, Jungsuwadee P. Chimeric antigen receptor T-cell therapy: Foundational science and clinical knowledge for pharmacy practice. J Oncol Pharm Pract 2019; 25:1217-1225. [PMID: 30890066 DOI: 10.1177/1078155219836480] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The Food and Drug Administration has recently approved two autologous chimeric antigen receptor T-cell immunotherapies tisagenlecleucel (Kymriah™) and axicabtagene ciloleucel (Yescarta™) for patients with advanced lymphocytic malignancies. Both immunotherapies target the CD19-positive B-cell neoplasms. Kymriah™ is indicated for the treatment of relapsed or refractory acute lymphoblastic leukemia and large B-cell lymphoma. Yescarta™ is indicated for lymphoma only. Although the new therapy offers a promise for patients with advanced disease, it is associated with adverse events including neurotoxicity and cytokine release syndrome, which can be fatal and may require a high level of multidisciplinary supportive care. Due to the risks, both Kymriah™ and Yescarta™ are subject to Risk Evaluation and Mitigation Strategy (REMS) protocols. As active members of multidisciplinary clinical teams, pharmacists are likely to be responsible for the execution of Kymriah™ and Yescarta™ REMS programs. This manuscript describes foundational science and clinical knowledge of chimeric antigen receptor T-cell immunotherapies, common therapy-specific toxicities and REMS requirements for Kymriah™ and Yescarta™ in relation to practice of pharmacy.
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Affiliation(s)
- Anna Dushenkov
- School of Pharmacy & Health Sciences, Fairleigh Dickinson University, Florham Park, NJ, USA
| | - Paiboon Jungsuwadee
- School of Pharmacy & Health Sciences, Fairleigh Dickinson University, Florham Park, NJ, USA
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48
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Abstract
Introduction The recent approval of CD19 chimeric antigen receptor (CAR) T cells for refractory or second relapse of B cell acute lymphoblastic leukemia (B-ALL) has led to a paradigm shift. Besides being an alternative to chemotherapy and antibody-based approaches, CAR-T cells have become the first successful example of "personalized medicine." Areas covered In clinical trials, tisagenlecleucel demonstrated higher response rates than prior therapies, and led to durable remissions lasting up to years for some children. Toxicities like cytokine release syndrome and neurotoxicity, while potentially reversible, have limited usage of CAR-T cells at certified centers with expertise in cellular therapy. Strategies to deal with B-ALL relapse after CAR-T remain an open area of research. Expert opinion Going forward, improvements will likely be seen in managing the side effects of CAR-T therapy as well as usage of CAR-T cells upfront as a replacement for chemotherapy or allogeneic bone marrow transplant for B-ALL. Further advances will need to reduce the biomanufacturing time needed to generate CAR-T cells as well as develop biomarkers that predict CAR-T persistence and/or toxicities.
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Affiliation(s)
- Christian M Capitini
- Department of Pediatrics and Carbone Comprehensive Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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49
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Boyiadzis MM, Dhodapkar MV, Brentjens RJ, Kochenderfer JN, Neelapu SS, Maus MV, Porter DL, Maloney DG, Grupp SA, Mackall CL, June CH, Bishop MR. Chimeric antigen receptor (CAR) T therapies for the treatment of hematologic malignancies: clinical perspective and significance. J Immunother Cancer 2018; 6:137. [PMID: 30514386 PMCID: PMC6278156 DOI: 10.1186/s40425-018-0460-5] [Citation(s) in RCA: 156] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 11/20/2018] [Indexed: 02/06/2023] Open
Abstract
Chimeric Antigen Receptor (CAR) T cell therapies - adoptive T cell therapies that have been genetically engineered for a new antigen-specificity - have displayed significant success in treating patients with hematologic malignancies, leading to three recent US Food and Drug Administration approvals. Based on the promise generated from these successes, the field is rapidly evolving to include new disease indications and CAR designs, while simultaneously reviewing and optimizing toxicity and management protocols. As such, this review provides expert perspective on the significance and clinical considerations of CAR T cell therapies in order to provide timely information to clinicians about this revolutionary new therapeutic class.
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Affiliation(s)
| | | | - Renier J Brentjens
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - James N Kochenderfer
- Experimental Transplantation and Immunology Branch, National Cancer Institute, Bethesda, MD, USA
| | - Sattva S Neelapu
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marcela V Maus
- Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - David L Porter
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - David G Maloney
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Stephan A Grupp
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Division of Oncology, Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Crystal L Mackall
- Cancer Immunology and Immunotherapy Program, Stanford University, Stanford, CA, USA
| | - Carl H June
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael R Bishop
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA. .,The University of Chicago, 5841 S. Maryland Avenue, MC 2115, Chicago, IL, 60637, USA.
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Mahmoudjafari Z, Hawks KG, Hsieh AA, Plesca D, Gatwood KS, Culos KA. American Society for Blood and Marrow Transplantation Pharmacy Special Interest Group Survey on Chimeric Antigen Receptor T Cell Therapy Administrative, Logistic, and Toxicity Management Practices in the United States. Biol Blood Marrow Transplant 2018; 25:26-33. [PMID: 30266675 DOI: 10.1016/j.bbmt.2018.09.024] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 09/16/2018] [Indexed: 10/28/2022]
Abstract
Administration of immune effector cell (IEC) therapy is a complex endeavor requiring extensive coordination and communication of various healthcare and administrative teams. Chimeric antigen receptor (CAR) T cells are the most established IEC therapy available. As of July 2018 two commercial gene therapy products, tisagenlecleucel and axicabtagene ciloleucel, have been approved by the US Food and Drug Administration. To gain insight into the infrastructure and practices across the country, the American Society for Blood and Marrow Transplantation Pharmacy Special Interest Group conducted an electronic survey on the current administrative, logistic, and toxicity management practices of CAR T cell therapy across the United States. This survey consists of 52 responses from institutions of varying sizes, most of which (∼80%) had previous investigational experience with CAR T cell therapy. Absorbing the energy of this exciting new treatment has challenged hematopoietic cell transplant programs across the country to strengthen department infrastructure, develop new committees and policies, and implement significant education to ensure safe administration. With the variety of experience with CAR T cell therapy, we hope this survey can contribute to the existing published literature and provide support and consensus to established and developing IEC programs and practice guidelines.
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Affiliation(s)
| | - Kelly G Hawks
- Department of Pharmacy, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Angela A Hsieh
- Clinical Strategic Intelligence & Pharmacy, McKesson Specialty Health, The Woodlands, Texas
| | - Dragos Plesca
- Department of Pharmacy, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Katie S Gatwood
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kathryn A Culos
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee.
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