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Oncology Nursing Month With Maria Badillo and Sherry Adkins: Nursing Considerations for CAR T-Cell Therapy

In honor of Oncology Nursing Month in May, Oncology Data Advisor is celebrating the stories of these essential members of the cancer care team. For this interview, editorial board member Maria Badillo, MSN, RN, OCN®, CCRP, speaks with Sherry Adkins, MSN, ANP-C, Advanced Practice Provider Supervisor at MD Anderson Cancer Center, about her groundbreaking research in the development of chimeric antigen (CAR) T-cell therapies and the critical role that oncology nurses play in caring for patients receiving this novel therapeutic strategy.  

Maria Badillo, MSN, RN, OCN®, CCRP: Good afternoon, Sherry. How are you doing?

Sherry Adkins, MSN, APN-C: Great, Maria. How are you?

Ms. Badillo: I'm good. Happy Nurses Week.

Ms. Adkins: Thank you, you too.

Ms. Badillo: Before we start our interview, I would like to give you a little background about Sherry. Sherry is an advanced practice nurse with over 20 years of experience. She completed her advanced practice oncology fellowship at the University of Texas Health Sciences 14 years ago, and then she began working as an inpatient nurse practitioner in the Department of Lymphoma/Myeloma at the University of Texas MD Anderson Cancer Center here in Houston. In 2016, she transitioned to lymphoma research and worked with Dr. Neelapu on the ZUMA-1 trial. The ZUMA-1 trial is actually the registry trial which led to the release of the first commercial CAR T-cell therapy for the treatment of lymphoma.

Sherry, can you give us a little bit of background of what you do right now? I believe you transitioned from research and now you're working with CAR T in the Department of Lymphoma/Myeloma. Can you please tell us what you do as APN?

Ms. Adkins: Sure. I am the supervisor for the advanced practice providers (APPs) in Lymphoma/Myeloma who are working with patients receiving CAR T-cell therapy. My focus with that group is in the outpatient setting, and it's delivering cells to patients on both research protocols and commercial products. I'm also looking at the program development for CAR T-cell therapy across our department.

Ms. Badillo: I believe I've worked with these CAR T protocols since 2015, and now there are many CAR T products that are available commercially. Can you please let us know, what are the roles of the nurse in terms of running CAR T trials or even commercial CAR T?

Ms. Adkins: Nurses are extremely important in delivering safe care for this group of patients, from the time of consent: through all the education they're doing with this patient population so that they know what to expect, through the time of apheresis and performing safe care during the apheresis procedure, as well as when the patients are then started on their therapy with lymphodepletion and receiving the cells. Nurses are vital in this timeframe, particularly after cell infusion, because they're the ones spending the most time with the patients. They're going to be the ones who are going to likely pick up on early signs that the patient's having potential toxicity related to this therapy, so they need to be very knowledgeable. Our nurses are very experienced in this therapy and really play a key role in providing this care safely to this group of patients.

Ms. Badillo: In terms of the toxicity you mentioned, we know that some of the toxicities we see for CAR T therapy are cytokine release syndrome (CRS) and neurotoxicity. How do you make sure that nurses are educated and know what signs and symptoms to look for in these patients?

Ms. Adkins: All the nurses who are delivering this care also have to go through the Risk Evaluation and Mitigation Strategy (REMS) program and take the REMS certification test, but there's a lot of education that is done on every new protocol so that they're aware of all the different aspects of the protocol. There's actually new material that's been developed recently to educate the nursing staff on this therapy. We also have the CARTOX mobile app, and the Epic automated flow sheet, which help them to identify and grade toxicities. That is key, because they're the ones reporting to the physician the grade of toxicity, which is what drives the management. We have all of those different tools that will help them in this endeavor to provide safe care.

Ms. Badillo: If our patients are infused with CAR T, what is the role of the nurses post–CAR T? I believe they are now being infused outpatient; is that correct?

Ms. Adkins: Some products are safe to give outpatient. Those patients receive their cells, and then they're seen daily for 10 days after the cell infusion by advanced practice providers in our ambulatory treatment center. Some products cannot be given safely outpatient; we choose to do those inpatient. The nurses are monitoring those patients continually, but they are grading toxicities every 12 hours, and obviously more often if the patients are developing those toxicities. They are the key people in helping to manage and alert other providers when patients are having difficulty.

Ms. Badillo: As we know, maybe half of our patients are coming from outside of Houston, right? What is the role of the nurse to ensure that safety is still being followed if the patient goes back home?

Ms. Adkins: At MD Anderson, we've developed a template for a follow-up letter that we send to the local oncologist. It goes over different aspects. First of all, what is the patient's response to the therapy? How often should we continue to monitor blood counts? What type of antimicrobial prophylaxis are they on? What recommendations do we have for vaccination? Where should they call if the patient develops a secondary malignancy? All of those things are in a letter that goes back to the local physician so that we can have some good continuity of care. We also give the patient a copy, and we tell them to carry that with them. If for some reason they end up getting admitted to a hospital that's not familiar with this type of therapy, they can show that letter to the caregivers there, and they'll have an understanding of the things that we should be watching for and what type of care they should have.

Ms. Badillo: Can you maybe tell us more about where you think nurses needs to be prepared on the next new treatments that are coming?

Ms. Adkins: Under the auspices of protocols, we're already using allogeneic CAR T cells. There are other treatments in the works, including bispecific antibodies. They are a big tool coming up in the armory that we have against lymphoma. There are new therapies coming out all the time. It's important that nurses stay up-to-date and educated on caring for patients whenever we develop these new therapies. As you know, Maria, we have something in our electronic medical record system called a fact sheet. For any patient who's on a protocol, the nurses can click on that fact sheet and quickly learn information that's vital in them caring for these patients is on that fact sheet. That's very helpful in helping to keep up with all the many trials that we have at MD Anderson.

Ms. Badillo: That's correct. Well, thank you so much, Sherry, for your time. Happy Nurses Week, and thank you for interviewing with me today. Thank you.

Ms. Adkins: Thank you so much, Maria. Happy Nurses Week.

About Ms. Badillo and Ms. Adkins

Maria Badillo, MSN, RN, OCN®, CCRP, is the Research Nurse Manager in the Lymphoma/Myeloma Department at The University of Texas MD Anderson Cancer Center. As a clinical trial manager, she develops research programs, manages protocol design and implementation, and coordinates patient participation in phase 1, 2, and 3 clinical trials. Ms. Badillo has been a speaker at several conferences, including the Oncology Nursing Society Congress and the Academy of Oncology Nurse and Patient Navigators Conference. Her research focuses on the development of novel therapeutics for patients with hematologic malignancies and the management of treatment-related adverse events.

Sherry Adkins, MSN, ANP-C, is the Advanced Practice Provider Supervisor in the Lymphoma/Myeloma Department at The University of Texas MD Anderson Cancer Center, where she specializes in the research and administration of CAR T-cell therapy. Ms. Adkins worked on the research team for ZUMA-1, the trial which led to the FDA approval of the first CAR T-cell therapy, axicabtagene ciloleucel for large B-cell lymphoma, in 2017.

For More Information

Neelapu SS, Locke FL, Bartlett NL (2017). Axicabtagene ciloleucel CAR T-cell therapy in refractory large B-cell lymphoma. N Engl J Med, 377:2531-2544. DOI:10.1056/NEJMoa1707447

MD Anderson Cancer Center (2020). IEC therapy toxicity assessment and management (also known as CARTOX) – adult. Available at: https://www.mdanderson.org/documents/for-physicians/algorithms/clinical-management/clin-management-cytokine-release-web-algorithm.pdf

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


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