This article first appeared in the April 2022 issue of Medical Professionals.

The expected survival for the patient population who has primary refractory disease is about six months. With the CAR T-cell treatment, we push that to at least three years.”
Alan Skarbnik, MD

Chimeric antigen receptor (CAR) T-cell therapy is now available for lymphoma patients at the Novant Health Cancer Institute in Charlotte. This newer treatment is considered if a patient isn’t responding to chemotherapy or if the cancer recurs. It uses a patient’s own cells to enhance their fight against cancer and recovery from chemotherapy by reprogramming a patient’s immune cells to attack and kill cancer cells.

In January, Novant Health Cancer Institute in Charlotte started providing outpatient CAR T-cell therapy for patients who have one of three types of recurrent or refractory lymphoma. These patients can access outpatient, as well as inpatient, CAR T-cell therapy. The institute is one of only 90 treatment centers in the United States that’s accredited to offer the game-changing therapy.

The institute first started using CAR T-cell therapy to treat blood cancers in 2018.

Skarbnik_Alan_Head
Dr. Alan Skarbnik

“CAR T-cell treatment has changed the treatment paradigm for recurrent lymphomas in the past few years,” said Alan Skarbnik, MD, director of the lymphoma and chronic lymphocytic leukemia program and director of the immune effector cell therapy program at Novant Health Cancer Institute. “But access to it is has been the main issue because there's a limited number of institutions that are able to offer this. We were very keen on bringing this technology to our patient population within Novant Health, so our patients have easy access to it.”

CAR T-cell therapy explained

This type of therapy is an immune effector cellular therapy that uses and engineers a patient’s lymphocytes to attack three types of recurrent or refractory lymphoma:

  • Diffuse large B-cell lymphoma
  • Mantle cell lymphoma
  • Follicular lymphoma

A patient’s T-cells are engineered to insert a chimeric antigen receptor, or CAR, that can recognize and guide the T-cell to a specific protein of interest that’s expressed by the cancer cells. The receptor binds to the protein, activating the T-cells to proliferate, expand and attack and kill the cancer cells.

“If you look at analysis from multiple clinical trials, the expected survival for the patient population who has primary refractory disease is about six months,” Dr. Skarbnik said. “With the CAR T-cell treatment, we push that to at least three years. So, it significantly changed the natural history here.”

The treatment process

It takes about 60 days, from assessment to infusion, to determine if a patient is a candidate for T-cell therapy. A thorough workup is performed to ensure the patient will be able to withstand the procedure and tolerate potential side effects.

It takes about 60 days, from assessment to infusion, to determine if a patient is a candidate for T-cell therapy. A thorough workup is performed to ensure the patient will be able to withstand the procedure and tolerate potential side effects.

  • T-cells are collected from the patient through apheresis at Novant Health Presbyterian Medical Center.
  • The cells are frozen and transferred to a facility, where the chimeric antigen receptors are introduced to the cells. It takes a total of about three weeks for the receptors to be introduced, for the cells to expand and for a quality assurance protocol to be completed.
  • The patient undergoes a short course (three days) of chemotherapy in preparation for the CAR T-cell infusion at Presbyterian Medical Center.
  • The patient rests at home for two days.
  • After two days of rest, the patient receives a 30-minute infusion by IV of engineered T-cells.
  • Monitoring and care for any side effects are provided on an outpatient basis or during a two-week inpatient stay at Presbyterian Medical Center.

Managing side effects

Creating inflammation that surrounds the cancer cells is the goal of the treatment, but it can cause systematic inflammation, which requires close monitoring.

With systemic inflammation, the patient may experience fever and chills. Neurotoxicity is also a side effect, causing headaches, confusion and seizures, which are rare. All of these issues are largely reversible, Dr. Skarbnik said, with appropriate and immediate interventions.

To qualify for outpatient CAR T-cell therapy, the patient must stay within an hour’s drive of Presbyterian Medical Center, in addition to meeting health criteria. For inpatient treatment, the patient must remain within a 90- to 120-minute drive to the medical center for follow-up appointments.

CAR T-cell therapy is covered by insurance and Medicare, Dr. Skarbnik said. Timely referrals for treatment are essential, he said.

“There is a lead time,” he said. “Having already evaluated and confirmed insurance benefits for CAR T-cell therapy for a patient in advance makes the process much easier.”

To refer a patient for assessment, contact the Novant Health Cancer Institute hematology and transplantation cellular therapy program at 980-302-6600.