Feeling Better? Why Follow-Up Care After Myeloma CAR T-Cell Therapy Is Essential

Katherine Banwell:

Daniel, sometimes patients feel well and may not keep up with their regular follow-up appointments. What’s the goal of follow-up care, and why is it essential?

Daniel Verina:

I think that’s very important because the way I have seen CAR T be promoted, it’s called the one and done. It’s vein to vein, I’m done with therapy. And really, what it stands for, in my opinion, is really the therapy, the physical giving the T-cells back is the one-time therapy, but it is a continual relationship, whether it’s with the community physician or the CAR T specialist at their academic centers for a lifelong, at least minimally, as we see in many years, if they have no disease going forward. So, the goal is to keep that care team in the loop lifelong, whether it’s your physician, hematologist. I think one of the things that also helps us look for is delayed responses, delayed side effects, two, three, four years later.

Are we seeing new side effects? But one of the things I find very interesting from my practice is many patients sometimes don’t have a primary care physician or general practitioner because they’ve gotten so accustomed to either their CAR T-cell physicians and team, or their community hematologist has become their family that they need to actually reach out to go to a primary care doctor for their age-appropriate screenings. Are they getting the proper care? I can only do so much. I always make a joke, I don’t do hypertension well.

I think that your primary care physician’s going forward – and also, making sure, I mean, it is FDA mandated that patients are followed up for approximately almost 15 years for the CAR T. So, again, knowing that they will be a lifelong in everybody’s lives is really important.

Katherine Banwell:

All right. Daniel, can you talk about revaccination after CAR T? Why is it necessary, and when does it need to happen?

Daniel Verina:

Absolutely. I mean, we’ve heard about vaccines. I come from a generation that we’ve been vaccinated since we were a child. So, again, it’s been part of our livelihood of healthcare screenings and prevention.

Revaccinations after CAR T is necessary because the treatment, and even prior chemotherapies, lymphodepletion, even auto stem cell transplants kind of erase our own history of immunity from childhood and earlier vaccinations. So, similarly, professionally societies also recommend that we revaccinate our patients regardless of their preexistent vaccination status. So, timing is kind of an important concept. So, we usually recommend either the COVID-19 vaccine, and the influenza, and the RSV vaccine three months after their CAR T.

Now, you can caveat that because if they’re at three months, and there in September, I always tell them to wait until the newer versions of the vaccines become available. But then, really starting at six months from the time from their CAR T, we start to really introduce the childhood vaccines.

So, the pneumococcal, the Hib, diphtheria, pertussis, we actually do hepatitis A and B, and then the inactive polio vaccine, they do it about six to 12 months. That seems to be the window of opportunity. And ASCO guidelines also suggest the same guidelines. And they’re all non-live vaccines. It’s extremely important to understand that we advise not to give any type of live vaccines, the measles, mumps, rubella, for an example. Usually, it’s the longest delay. And we usually wait about one to two years after a patient’s CAR T. So, if they’re not on any active treatment, about two years later, only if their immunity, like their CD4 count is generally above 200.

And they have good immunotherapy – or immunoglobulins. That was the word I really wanted to say. Their immunoglobulins are a healthy level. So, about two years after, we will consider MMR.