CAR T-Cell Therapy Continues to Revolutionize Hematologic Cancer Treatment

Kelly Garvin, BSN, RN, OCN

The number of FDA approved CAR T-cell therapies has increased from 3 to 5 drugs in the past year. This novel treatment regime shows promise to continue to evolve in the coming years, providing hope for patients with relapsed hematologic malignancies that failed to respond to prior chemotherapy treatments, says Kelly Garvin, BSN, RN, OCN.

In a recent interview with Oncology Nursing News®, Garvin, from the Department of Malignant Hematology, H. Lee Moffit Cancer Center, discussed her recent presentation on the drug landscape at the 5th Annual School of Nursing Oncology meeting. She outlined how nurses can remain vigilant in detecting CAR T-related adverse events (AEs), and commented on how the evolution of CAR T-cell therapy has continued to change the prognosis for patients with blood cancer and where she hopes the treatment direction will go.

Oncology Nursing News: How can nurses anticipate, and respond aggressively to, CAR T-cell therapy-related AEs?

Good question. One thing that we do is we have specially trained nursing staff. So, the nurses that work on the CAR T-cell floor are almost intensivists. In other words, we can float nurses from the intensive care unit to the CAR T-cell floor, but we cannot load nurses from MedSurg to the CAR T[-cell therapy] floor. So, these nurses, first of all, have to be specially trained in how to recognize the signs and symptoms of cytokine release syndrome, neurotoxicity, and ICANS.

Another thing that we do is we take vital signs more often. So, instead of [taking vitals] once a shift, we do it every 4 hours. We can do a cranial nerve check every time we go in there. We can be on the lookout for signs like headaches, aphasia, or confusion. We can ask the patient to write out a sentence and notice if there's any tremors in their penmanship that might be indicative that something is brewing. We can take their temperature more often. We can use family members to help us and alert us if the patient seems a little off. So, things like that all work together to keep the patient safe.

Would you be able to comment on how CAR T-cell therapy has changed the outcomes and prognosis of patients with blood cancers?

Oh, this is my favorite thing to talk about. So much has happened recently. Last year, I gave this talk, and, at the time, there were only 3 products that were FDA approved for certain malignancies, and 1 of them had been approved days before I gave the talk. In fact, I had to redo all the slides just to include them. Now, there are 5 different products and there are more indications.

So, if I have a patient who, for example, [has] diffuse large B-cell lymphoma, 1 of the most common non-Hodgkin lymphomas diagnosed in the United States every year, and is very aggressive, [the] good news is that we can cure about two-thirds of these patients with traditional archtop chemotherapy and immunotherapy. But for the one-third who relapse, or don't respond, the data is not good. There's not much we can do. Standard of care says [to] try salvage chemotherapy and then take them to autologous stem cell transplant. But if chemotherapy didn't work that well the first time what's to say heavy duty chemotherapy is going to work the second time. Right now, there's a trial going on in my cancer center looking at whether CAR T-cell therapy is just as good or maybe even better than standard of care. So, for patients who maybe have poor prognosticating factors, like bad genetics, or maybe they have BCL2 or BCL6 translocation or overexpression, and it doesn't look like they're probably going to respond very well to chemotherapy, if we could take those patients, and identify them early and take them to CAR T-cell therapy, where we're not using chemotherapy to fight the disease, we're using the body and the patient's own immune system, might they have a better outcome? Might their remission be deeper and longer? That's what we're going for.

And what do you hope to see in the next 5 to 10 years?

So many good things. So, one of the hurdles that we have to get over with CAR T-cell therapy is that we're using the patient's own T cells, and we're sending them off to be manufactured and to be reprogrammed in a way that is better able to fight the cancer. But sometimes that process takes too long. These are patients who have seen multiple lines of therapy. By the time they get to CAR T-cell therapy, they might not be able to wait the 2, 4, or, in some cases, even 6 weeks to get those T cells manufactured for them. So, 1 thing that we're looking at is allogeneic T-cell therapy or off-the-shelf [therapy]. So, we'll have donor T cells, kind of like we have donor allogeneic stem cell transplant. So that's 1 area.

Another area is more indications. Can we use CAR T-cell therapy for other diseases? For example, follicular lymphoma, which often transforms into diffuse large B-cell [lymphoma], can we use it in follicular lymphoma, just like we can in diffuse large B-cell [lymphoma] to get better outcomes for these patients? As a matter of fact? Yes. Axicabtagene ciloleucel (Yescarta), the first generation CAR T-cell therapy, just became approved in that particular setting as well.

Another thing I'd like to see is maybe using CAR T-cell therapy as first[-line therapy] rather than in the relapsed/refractory setting. So, would it be better to maybe replace chemotherapy sometimes or replace stem cell transplant in some cases, and start with CAR T-cell therapy for some of these patients, especially if they have TP53 mutations, or other genetic markers that lead us to suspect maybe they're not going to respond very well to chemo? Let's start thinking: Can we use immunotherapy instead? That's what I'd like to see.

What is the grand takeaway for oncology nurses from your presentation?

Well, on a very tangible level, nurses who already do oncology and who see patients that have these B-cell malignancies, these multiple myelomas and these diffuse large B-cell [and[ follicular or mantle cell [lymphomas], they’re going to know how to prepare the patients that they've identified as good candidates for what CAR T-cell therapy will feel like and look like for the patient. So that's 1 thing.

And for the other nurses who maybe don't do lymphomas, I want to leave them with this idea: CAR T-cell therapy is huge. It's exciting. It's dynamic. And it's a very fun place to be in medicine right now. And stay tuned, more is coming down the pipeline.