Myeloma CAR T-Cell Therapy | Long-Term Recovery

Transcript

Laura Beth Ezzell: 

All right, so, let’s now consider the long-term recovery here. A close monitoring is still important, obviously, as time passes. So, what are the symptoms that appear in the months after treatment?  

Dr. Ciara Freeman: 

So, it can sometimes depend on the product received. So, there are some products that we are a little bit more cautious for, in terms of longer-term late onset relapses or toxicities. So, there are certain products where we’ll tell patients, even though you’re going home, if any of these things happen, we’ll want to make sure that you let us know early, and don’t sort of write it off as not something that’s important to report.  

Some of the things that we watch out for are unusual, uncommon neurological side effects that some patients can report. So, we’ll usually have quite a detailed sit-down with a patient at Day 30, and explain to them, “These are the things I want you to tell me, if they’re occurring. Even if you think it might not be related, I want you to let me know.” 

Any patient with multiple myeloma, regardless of the stage of their disease, is, unfortunately, at increased risk of secondary malignancies. So, that’s other cancers outside of their myeloma. So, any patient I meet, whether it’s newly diagnosed, early relapse, late relapse, I’ll always tell them, “Let’s make sure that we don’t forget about keeping an eye out for those other cancers.”  

And those could be your standard age-and-sex-based screenings like mammograms, and keeping an eye on your prostate, if you’re a man, and colonoscopies, if you need them. These are all things that I also want to make sure is incorporated into every patient’s long-term for survivorship plan.  

Laura Beth Ezzell: 

Yeah, and how long will patients need to be on preventative antibiotics or antiviral medications?  

Dr. Ciara Freeman: 

So, the antibiotics, we stop early. As soon as the patient’s recovered what’s called a neutrophil count above a certain threshold, we will not continue those antibiotics. There are certain medicines that we do continue. So, the antiviral, continue to the first year after CAR T-cell therapy, and that’s just to make sure they don’t have a shingles reactivation. 

Our patients are always at increased risk, and we’ve taken the same approach that we take from after transplant; and we sort of translated that across to post-CAR T, and we continue that for a full year. And thankfully, we see very few shingles reactivations as a result of that approach. The other thing we watch out for is preventing a sort of very unusual infection called PJP, and we basically keep a very close eye on a certain component of the patient’s immune system.  

And as soon as that’s recovered, we stop the medicine for that; but that’s either a low dose – I guess it is a low-dose antibiotic, or a preventative medicine for that, to make sure that those patients don’t end up getting that nasty lung infection, if it occurs. Because the antibiotic is so narrow in its spectrum. And so, devoid of side effects, we tend to continue that, until they’ve recovered that T-cell component that helps protect them from.  

Laura Beth Ezzell: 

Excellent. And this is a question that definitely keeps coming up through my mind. When is it safe to let your guard down a little bit?  

Dr. Ciara Freeman: 

So, I think that’s a question that we’ve never been fortunate enough to ask in the myeloma field until very recently. So, many of the patients who are watching this today may be familiar with the data that came out not that long ago, from the long-term follow-up of one of the most potent CAR T-cell therapies, where patients who had been followed out beyond five years, there was a third of patients who were treated in that study who were still in remission after five years.  

And that is on no therapy, on no ongoing treatment, no maintenance, no sneaky chemo put in here and there; and that was a very sort of provoking piece of data to come out for the myeloma community, thinking to ourselves, is it possible?  

Is it possible it might not come back? I think we’re still nervous to say the C word out loud for patients with myeloma, and that’s something that we’re getting more and more excited about. What does that mean? What would functional cure look like? 

How long would they have to be disease-free, in remission of therapy, for us to say you are free of myeloma forever? And from the point of view of me as a patient, as a provider who looks after patients with CAR T-cell therapy, as long as they are well, if they’ve had CAR T-cell therapy, I’ll never discharge them. I will see them less frequently, but I will not let them out of my practice. I’ll keep an eye on them.  

And that’s just good survivorship care. I think it’s mandatory for us to follow these patients, because it’s still an evolving field, and it’s important for us to know what happens, and follow them for as long as they’re alive. And hopefully, as I tell my patients, “I hope that you live long enough to die from something else, and it’s not the thing that you see me for.”