Streamlining "Brain-to-Vein" Time, Patient Selection, Imperative for Implementing CAR T for MM

The advent of chimeric antigen receptor (CAR) T-cell therapies has brought numerous advantages to the multiple myeloma treatment landscape; however, implementing these therapies into clinical practice comes with its own challenges.

In this interview with The American Journal of Managed Care^®, Ajai Chari, MD, University of California San Francisco, points specifically to operational delays that extend “brain-to-vein” time and hamper efforts to provide these therapies on the community level. Navigating these challenges, he adds, makes patient selection all the more important for guiding treatment approaches.

This transcript has been lightly edited; captions were auto-generated.

Transcript

What are the biggest operational challenges in bringing CAR T-cell therapies to the clinic, and how can health care systems streamline their adoption?

The overarching starting point would be these are unprecedented in terms of their activity in relapse/refractory myeloma. We're seeing 60% to 100% response rates with remissions lasting 1 to 3 years in patients who literally could have been hospice bound. The question is, how do you deploy that to the entire patient community? And [it] has different operational challenges.

With CAR T, I think the best way to summarize it is: how do we decrease the “brain-to-vein” time? What that means is 80% of patients [with myeloma] in the US are being treated in the community. From the moment that a community doctor thinks about CAR T for a patient, and because they're only being done at specialized centers, they have to be referred to the academic center; the academic center has to do the consultation; then you have to submit for insurance approval; then there needs to be an apheresis slot; then the cells need to be collected—the T cells need to be collected and sent off. That can take anywhere from 4 to 6 weeks currently. And then when those cells are ready, then you have lymphoid depletion, chemotherapy, and then you actually get to a CAR T.

When you think about not just brain-to-vein time, because people want to historically talk about apheresis to CAR T infusion. It's really brain-to-vein, which is community doctor to the CAR T. I think that process is inherently cumbersome, and what that means is you cannot have patients who are rapidly progressing go through CAR T. [What] we've seen in randomized phase 3 [trials] is that when you do CAR T vs standard of care for the first few months, there's a crossover in both progression, presurvival, and overall survival. What's happening is the patients who can't wait to get to CAR T are having progression complications and even deaths prior to CAR T or during the CAR T. And so patient selection is important.

The last point I would make for CAR T is you need to pick the right patients. Patients who can tolerate high-grade CRS [cytokine release syndrome]—so probably not the frail elderly, [those with] significant heart failure, renal failure. I think that's the other part of that. That would be my response for operational challenges with CAR T.

The last part, from a payer perspective, is these are very expensive products. They're $500,000 to $700,000 list price. But in return for that, you do have a long treatment-free interval, potentially up to 3 years or longer. It’s quite cost-effective when you think about it like that. But the only thing is, people think it's a one-and-done [treatment], but it's not that simple. We talked about getting to CAR T, but after CAR T, there's IVIG [intravenous immunoglobulin] transfusions, supportive care, [and] antibiotics. It can take up to 6 months to really be “completely visit free.” But in the long term, you've saved all the expensive chemotherapy that needs to be given routinely in a chronic disease.