Transitioning Patients Back to the Community Setting After CAR T Therapy for B-Cell Lymphoma

Lynch describes the individualized approach to determining community transition timing, now flexible between 14 and 30 days post infusion following REMS dissolution. Decisions depend on ongoing toxicities and community team comfort levels. Hematologic toxicities represent the most common transition challenge, often requiring granulocyte colony stimulating factors or thrombopoietin mimetics with frequent communication between academic and community teams through various channels including email, in-basket messages, and phone calls.

Common late toxicities include hypogammaglobulinemia requiring intravenous immunoglobulin and frustrating autonomic dysfunction presenting as orthostatic hypotension. Patients often require medications like midodrine and fludrocortisone while discontinuing previous antihypertensives. Managing these medications presents challenges with limited evidence-based guidance, requiring trial-and-error approaches typically involving gradual fludrocortisone reduction followed by midodrine tapering, sometimes with cardiology consultation.

Brain fog and cognitive changes represent additional challenges requiring patient reassurance about gradual improvement over time. Lynch emphasizes maintaining open communication channels with community providers, offering regular availability for questions and collaborative problem-solving. The goal involves supporting community oncologists through education and consultation while ensuring patients receive seamless care transitions that maintain treatment gains achieved through CAR T therapy.