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Caring for Patients Receiving CAR T-Cell Therapy With Joshua Sasine, MD, PhD

In this interview with Oncology Data Advisor, Dr. Joshua Sasine, Hematologist-Oncologist at Cedars-Sinai Medical Center, discusses the factors that make patients suitable candidates for chimeric antigen receptor (CAR) T-cell therapy, strategies to minimize the unique toxicities associated with these treatments, and the future of the use of CAR T-cell therapy in the outpatient setting.  

Oncology Data Advisor: Welcome to Oncology Data Advisor. I'm Keira Smith. Today I'm here with Dr. Joshua Sasine, who is here to share his advice on caring for patients receiving CAR T-cell therapy. Thank you so much for joining us today.

Joshua Sasine, MD, PhD: Sure, I'm a Hematologist-Oncologist and I work at Cedars-Sinai Medical Center. I'm interested in cellular therapies. I routinely do bone marrow transplants and treat patients with CAR T cells. I'm also a physician-scientist, and I have a research laboratory where we study how leukemias and other blood cancers work, and also how cell therapies can be improved.

Oncology Data Advisor: So, what are the factors that are considered when selecting patients for treatment with CAR T-cell therapy?

Dr. Sasine:Well, we first look at the indication. The patient has to have a disease that would be amenable to CAR T-cell treatment. Right now, that's mainly limited to multiple myeloma and certain types of leukemias and lymphomas. But if the patient has an indication for which a CAR T-cell product would be potentially helpful, then we offer that treatment to the patient if they are physically healthy enough to undergo the treatment, because the toxicity can be quite serious for some patients. We want to make sure that their heart function, their lung function, and the rest of their body is healthy enough to endure the potential for serious side effects.

Then we make sure that the patient has adequate housing and social support, because there's a period of monitoring where we don't want them to be alone. If all of those things align and we discuss the pros and cons of treatment with the patient, and if the patient would like to proceed, then we move forward with it.

Oncology Data Advisor: For clinicians who are managing patients receiving CAR T-cell therapy, do you have any strategies for how to manage these toxicities?

Dr. Sasine: Yes. So far, the community is not managing CAR T-cell therapy yet. They're managing bispecific antibodies, which have similar toxicities, but we're hoping that this will increase in the community and that this will come out of the tertiary care medical centers into the average community oncology practice. If that were to occur, then we would need to do a lot more setup with the logistics. In fact, most of the barrier would actually be regulatory, but the toxicity management could be done.

The advice I would give is to try to select patients early in their treatment journey, whether they're doing it themselves or being referred to us, because the earlier, the better. The treatment takes a long time to set up. In the meantime, we need to control the disease and we need enough time to do that. If the patient has no other therapies left and their cancer is progressing uncontrolled and then we treat them with a CAR T, that can be a dangerous situation, because we want the patient to have a low burden of disease when we treat them. Otherwise, that amplifies the toxicity; in some cases, tragically, the patients are not able to receive the CAR T because their disease progresses during the time that we're arranging all of this. So earlier is better.

There are also some emerging data showing that perhaps treating patients earlier yields better T cells and makes the CAR T treatment even more effective. So yes, earlier is better. Treating patients with a low burden of disease, if possible, is better. Giving the patients enough time to digest the potential toxicities is very important. This is not something you want to do because the patient's disease is progressing out of control and you're running out of time, because that just adds to the stress of the whole procedure.

Right now, we're mainly doing it in the hospital, and by "we," I mean the entire community of CAR T treaters. We're hopeful that we could make this, say, an outpatient procedure more routinely for patients and then have a way to quickly get them into the hospital and manage their toxicity expeditiously when that time comes. It's logistically difficult to set that up, but it's something that is of great interest, especially given the number of patients that are going to be eligible for CAR T-cell treatments in the future as the indications expand. It's very difficult to build new hospitals and get more beds. To be able to offer this to as many patients as possible, we're going to need some way to decrease the hospitalization time. The best way to do that is by giving it as an outpatient.

Oncology Data Advisor: Do you have any additional words of advice on caring for patients receiving these therapies?

Dr. Sasine: One thing to add is that for now, I don't think we're able to offer this to as many patients as we would like. The reason for that is because we don't get as many referrals as we would like. I don't just mean our center; I mean all of the CAR T treating centers. If you look at the number of patients epidemiologically who could get it versus the number who do get it, there's a very big gap. We would like to try to close that gap. Now, not every patient is going to be a CAR T cell candidate by virtue of the co-occurring sicknesses that they might have or some of the other reasons I mentioned. But I think we could do much better than we are. I think part of that is that it takes a referral for now to get the CAR T treatment. It takes a referral to the tertiary care center.

I would love to see more patients referred for evaluations. I suspect there are a great many patients who could get the treatment if they would be referred. I think despite the toxicity concerns, which are real and potentially serious, even patients with co-occurring illnesses like chronic kidney disease or other types of problems would often still be eligible for the treatment if we were able to see them and formally evaluate them. I would encourage everyone within the sound of my voice to increase the number of patients who get evaluated for this treatment. If it's not safe or advisable, that's okay, but it's better to know that, given that CAR T-cell treatment can cause quite durable remissions in patients who receive it, and these remissions on average are much more durable than anything else on offer.

Oncology Data Advisor: Well, thank you. These are a lot of really practical solutions, so thank you so much for explaining all of them.

Dr. Sasine: Thanks for having me.

About Dr. Sasine

Joshua Sasine, MD, PhD, is a Hematologist-Oncologist and an Assistant Professor at Cedars-Sinai Medical Center in Los Angeles, California. He specializes in the treatment of patients with multiple myeloma, lymphoma, and chronic lymphoid leukemia, with particular expertise in bone marrow transplant and CAR T-cell therapy. Dr. Sasine's research focuses on the development of novel treatments for hematologic malignancies and the use of novel cell therapies to deliver macromolecules to cancer cells.

Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of Oncology Data Advisor. 


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