Better understanding of late effects needed to guide survivorship care after CAR-T
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Little is known about the long-term issues facing cancer survivors who received chimeric antigen receptor T-cell therapy, primarily because the therapy is relatively new.
Until the number of patients who undergo CAR-T increases and survivors are followed for longer periods, clinicians can draw on the experience of patients who have undergone hematopoietic stem cell transplantation, according to Areej El-Jawahri, MD, director of the Bone Marrow Transplant Survivorship Program at Mass General Cancer Center.
In this installment of In Practice, El-Jawahri spoke with Healio about how to prepare patients for possible long-term effects of CAR-T, current knowledge gaps, and how emerging research will compare survivorship considerations of patients who have received HSCT and cellular therapies.
Question: How much information is available about the long-term effects of CAR T-cell therapy?
There are limited data on long-term effects into the survivorship phase. There is a growing body of evidence regarding the effects of CAR T-cell therapy during the first year following treatment. However, we need a more comprehensive understanding of late effects 2 years and beyond after therapy.
Q: What do you advise patients to expect once they are released from the clinic?
We extrapolate based on our knowledge of survivorship concerns among lymphoma survivors, as well as stem cell transplant survivors. We acknowledge the importance of cardiovascular and bone health. We discuss some of the common late effects seen in the context of survivorship care and oncology, but we also recognize the limitation of our current knowledge and the need for more robust data from patients who received CAR T-cell therapy.
Q: What is the most significant issue patients face after receiving CAR T-cell therapy?
Patients often struggle with concerns about disease recurrence and cancer progression within 2 years of receiving therapy. These patients likely face important late effects due to cumulative effects of previous therapies, including late cardiovascular effects, secondary malignancies, diminished bone health, endocrine abnormalities and the psychological burden associated with cancer treatment.
Q: Are there any other significant issues?
Neurocognitive effects and long-term neurological issues are important to consider and are currently unknown for patients who received CAR T cells. Early data suggest that patients may return to baseline levels neurocognitively within 1 year of therapy. However, we need additional longitudinal data to better characterize the trajectory of neurocognitive effects in this population.
Q: Do children and adolescents have specific post-infusion survivorship needs to consider compared with adults?
Indeed, pediatric patients face important issues regarding fertility and endocrine late effects that are critically important and likely similar to many of the issues facing pediatric patients who receive other cancer therapies.
Q: Are you conducting any research in this area?
We are focused on better understanding the physical and psychological symptoms of patients who have received CAR T-cell therapy, along with their quality-of-life trajectory. We are also conducing longitudinal assessments to characterize neurocognitive function in CAR T-cell therapy recipients. These descriptive data will be essential to understand the long-term supportive care needs of these patients.
Q: How do posttreatment toxicities differ when comparing CAR T-cell therapy with HSCT?
Both populations have received previous cancer therapy and are heavily pretreated, which predisposes them to additional risk for late effects and potential toxicities. However, early data suggest that quality of life and overall functioning among CAR T-cell recipients may recover faster than among autologous or allogeneic HSCT recipients. Importantly, chronic graft-versus-host disease is a major cause of late morbidity and mortality in allogeneic HSCT recipients but is not an issue for CAR T-cell therapy recipients.
Q: Are centers that already perform HSCT equipped to provide the same support to patients who receive CAR T-cell therapy?
Typically, centers that have robust HSCT survivorship programs are well-poised to deliver survivorship care for CAR T-cell therapy recipients. However, we must individualize and tailor therapy as we gather more data on the needs of patients who receive CAR T-cell therapy.
Q: What resources are needed to provide patients with successful survivorship navigation after CAR T-cell therapy?
We have a survivorship program that can accommodate these patients and help address their survivorship and supportive care needs. We also have a social worker who attends to the psychosocial needs of these patients.
Q: Do you consult professional guidelines during your consultation and decision-making process?
Yes, we work closely with the American Society for Transplantation and Cellular Therapy when it comes to following guidelines in providing care for all our HSCT and CAR-T cell therapy recipients.
For more information:
Areej El-Jawahri, MD, can be reached at Mass General Cancer Center, 55 Fruit St., Yawkey 9E, Boston, MA 02114; email: ael-jawahri@partners.org.
To contribute to In Practice or to suggest topics, email us at CellTherapyNext@healio.com .
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