Bijal Shah, MD, MS, associate member, Department of Malignant Hematology, Moffitt Cancer Center, and Michael Wang, MD, professor, Department of Lymphoma & Myeloma, The University of Texas MD Anderson Cancer Center, discuss the need for collaboration between academic and community practices for patients who receive CAR T-cell therapy.

Integrating primary care physicians into the post–CAR T-cell therapy management of patients with hematologic malignancies is difficult, Shah and Wang explain. In many cases, engaging community practices has not been a priority; however, primary care physicians can closely monitor heart function and recovery of immunoglobulin while supporting the patient. 

Gaps in communication still exist, particularly when patients come into the emergency room with CAR T-cell therapy–related complications, such as infections. Moreover, these gaps have been further exacerbated with the onset of the COVID-19 pandemic, Wang says.

Aggressive treatments with vaccines, IVIG, and prophylactic antibodies for patients who develop infections after CAR T-cell therapy are helpful, but managing patients who develop CAR T-cell therapy–related complications away from the center in which they received CAR T-cell therapy is challenging. Furthermore, this underscores the need for close collaborations and partnerships between academic and community practices, Shah concludes. 

Videos

Bijal Shah, MD, MS, and Michael Wang, MD, discuss the need for collaboration between academic and community practices for patients who receive CAR T-cell therapy.  



Dr. Shah and Dr. Wang on the Need for Academic and Community Collaboration With CAR T-Cell Therapy 

Bijal Shah, MD, MS, associate member, Department of Malignant Hematology, Moffitt Cancer Center, and Michael Wang, MD, professor, Department of Lymphoma & Myeloma, The University of Texas MD Anderson Cancer Center, discuss the challenges of managing high-risk mantle cell lymphoma (MCL).

High-risk MCL is characterized by blastoid or 

 variants and can grow quickly, Shah explains. As such, identifying these patients early to ensure all potential treatment options are available for use is critical. For example, patients with high-risk disease who are not identified early may be ineligible for CAR T-cell therapy, which requires apheresis and bridging therapy, Shah says. Moreover, although indolent MCL may be actively monitored, high-risk MCL often requires aggressive treatment. 

Currently, a gap between referring community practices and academic practices exists because community practices may not be as familiar with identifying high-risk disease. As such, sharing knowledge of markers of high-risk disease and the differences between indolent and high-risk MCL is an important step to bridge that gap, Wang concludes. 

Bijal Shah, MD, MS, and Michael Wang, MD, discuss the challenges of managing high-risk mantle cell lymphoma.



Dr. Shah and Dr. Wang on the Challenges of Managing High-Risk MCL 

Bijal Shah, MD, MS, associate member, Department of Malignant Hematology, Moffitt Cancer Center, and Michael Wang, MD, professor, Department of Lymphoma & Myeloma, The University of Texas MD Anderson Cancer Center, discuss navigating the referral process for CAR T-cell therapy in hematologic malignancies.

Referring patients for CAR T-cell therapy can be a challenging process, Shah explains. Patients who receive CAR T-cell therapy are expected to stay in or around the treatment center for 2 to 4 weeks, depending on the severity of CAR T-cell therapy–related toxicities, Wang says.

Ultimately, close collaboration between community and academic practices is needed to ensure the referral process is optimal for patients, Shah and Wang conclude.

Bijal Shah, MD, MS, and Michael Wang, MD, discuss navigating the referral process for CAR T-cell therapy in hematologic malignancies.  



Dr. Shah and Dr. Wang on Navigating the Referral Process for CAR T-Cell Therapy in Hematologic Malignancies 

Bijal Shah, MD, MS, associate member, Department of Malignant Hematology, Moffitt Cancer Center, and Michael Wang, MD, professor, Department of Lymphoma & Myeloma, The University of Texas MD Anderson Cancer Center, discuss management strategies for CAR T-cell therapy–related cytokine release syndrome (CRS) and neurotoxicity in leukemia and lymphoma.

Earlier integration with tocilizumab (Actemra) and, in some cases, corticosteroids has been effective in mitigating emerging CRS in patients with leukemia or lymphoma who receive CAR T-cell therapy, Shah says. However, determining when to intervene with these therapies can be difficult and requires balance.

For example, early intervention with steroids can hinder T-cell expansion, whereas late intervention can leave a patient with more severe CRS that is associated with high fever, hypotension, and hypoxia, Wang explains. Moreover, untreated neurotoxicity can cause seizures and late-onset toxicities. 

As such, one strategy for managing CRS includes early intervention with tocilizumab, punctuated doses of corticosteroids, and close monitoring, Shah explains. However, tocilizumab does not treat neurotoxicity and, although effective, utilizing steroids sparingly can exacerbate neurotoxicity. Ultimately, a balance between therapeutic intervention and managing emerging CRS and neurotoxicity is needed, Shah and Wang conclude.

Bijal Shah, MD, MS, and Michael Wang, MD, discuss management strategies for CAR T-cell therapy–related cytokine release syndrome and neurotoxicity in leukemia and lymphoma.  



Dr. Shah and Dr. Wang on Managing CRS and Neurotoxicity in Leukemia/Lymphoma  

Bijal Shah, MD, MS, associate member, Department of Malignant Hematology, Moffitt Cancer Center, and Michael Wang, MD, professor, Department of Lymphoma & Myeloma, The University of Texas MD Anderson Cancer Center, discuss the main CAR T-cell therapy–associated toxicities in hematologic malignancies. 

Cytokine release syndrome (CRS) and neurotoxicity are unique toxicities commonly associated with CAR T-cell therapy in patients with hematologic malignancies, Shah says. Additionally, infections can arise with this treatment because CAR T-cell therapy is thought to enhance B-cell aplasia. This compromises cellular immunities and makes patients susceptible to potentially life-threatening infections, Wang explains. It is important to monitor patients with hematologic malignancies who receive CAR T-cell therapy for potential cardiac toxicities as well. 

Although the toxicities associated with CAR T-cell therapy are broad, they are routinely seen in real-world clinical practice and require specialized management, Shah and Wang conclude.

Bijal Shah, MD, MS, and Michael Wang, MD, discuss the main CAR T-cell therapy–associated toxicities in hematologic malignancies.  



Michael L. Wang, MD University of Texas MD Anderson Cancer Center

Articles

Dr. Shah and Dr. Wang on the Need for Academic and Community Collaboration With CAR T-Cell Therapy

Dr. Shah and Dr. Wang on the Challenges of Managing High-Risk MCL

Dr. Shah and Dr. Wang on Navigating the Referral Process for CAR T-Cell Therapy in Hematologic Malignancies

Dr. Shah and Dr. Wang on Managing CRS and Neurotoxicity in Leukemia/Lymphoma

Dr. Shah and Dr. Wang on CAR T-Cell Therapy–Associated Toxicities in Hematologic Malignancies