Making the Decision to Undergo CAR T-Cell Therapy? Crucial Considerations.

Transcript

Jamie Forward:

What other important considerations are there for someone that’s making the decision to undergo CAR T-cell therapy?

Dr. Danai Dima:

So, a few things. I think an important consideration for CAR T is first, the occurrence of severe delayed complications, which are rare but can be permanent. So, one of them is delayed neurotoxicity. That includes nerve palsies or even parkinsonism. And it can occur in around one to three percent of patients. We still do not know the exact mechanism or this.

And therefore, management is pretty limited and ineffective in resolving parkinsonism, unfortunately. Other important delayed toxicities include the development of secondary primary malignancies such as leukemias and lymphomas. These events are rare, often taking months or years to develop and are still under active investigation. Lastly, patients might suffer from recurrent or chronic infections, especially if their cytopenias are persistent for months after the infusion.

And for this reason, patients need to receive long-term prophylaxis with antibiotics or IVIG. So, I think understanding all those delayed adverse events is really important.

So, as doctors, we should have an open and honest discussion with patients about the potential for these delayed toxicities.

While the majority of patients do not experience these complications, they are possible, and in some cases may be serious and long lasting or irreversible. So, as a part of the informed consent process, patients should be counseled not only about the early toxicities but also for the delayed ones.

Another thing aside from toxicities I think patients need to understand, the mandatory requirement for a caregiver. We do have patients who come to us for CAR T consultations, but then there’s no dedicated caregiver. So, this is a dealbreaker.

And when the patient walks into my office, and they’re requesting CAR T, I always ask them, “Look, you need to have a primary caregiver. And if you live far, you need to relocate close to our center for at least a month.” So, these are the two main things that patients need to consider.

And sometimes, we’ve seen that maybe there’s not a dedicated caregiver right at the moment, but assessing and evaluating a patient for CAR T is a dynamic process. So, I always urge patients to try to figure it out. And maybe we cannot do CAR T now, but we might be able to do CAR T in six months or a year. So, this is just a constant reevaluation. Other than that, deciding whether CAR T is appropriate for a patient, there are other things that we look at as doctors. For example, what treatments patients have received before the CAR T-cell therapy, or how does the myeloma behave at the moment when the patients are referred for CAR T?

For example, sometimes if patients have rapidly progressing disease or they have a lot of extramedullary disease, we know CAR T-cell therapy might not be a great option at the moment, so we might go with something else.

And sometimes, patients are also older and frail. So, in these cases, we might consult the patient that CAR T’s an option, but there are other treatments that could be as effective and more safe. So, we might go with that for now and reassess you for CAR T later because even frailty is a dynamic assessment process. If a patient is frail now, it doesn’t mean that they’re going to be frail after six months or a year because sometimes when the disease gets better, the frailty gets better.