Which Patients Are Not Well Suited for CAR-T Therapy?

A roundtable discussion, moderated by Sagar Lonial, MD, FACP, Blood Cancers Today Editor-in-Chief, of the Winship Cancer Institute at Emory University School of Medicine, focused on the latest updates in CAR T-cell therapy for multiple myeloma. Dr. Lonial was joined by Noopur Raje, MD, and Krina Patel, MD, MSc.

In the next segment of the roundtable series, the panel discusses which patients may not be suitable for CAR T-cell therapy.

Watch the next segment in this series.

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Dr. Lonial: Let me take you through a little bit, because I think so far, we’ve had a pretty broad conversation. We know that there is attrition in terms of who gets into a trial. There’s attrition in terms of who gets the actual product versus the people we want to give the product to. I’m going to reverse the question a little bit and say, who wouldn’t you give a CAR [chimeric antigen receptor] to from a safety perspective?

Dr. Raje: I would say I would give a CAR to pretty much all my patients. The only patient where I would be a little bit concerned about is if they’re rapidly progressing and I need to do something to control their disease. Because it is still taking us four to six weeks to get the CAR product.

From a safety standpoint, I have no concerns. The older days we used to worry about kidney function. We’ve done CAR T cells with significant kidney impairment and we’ve just dose-reduced, dose-adjusted or gotten rid of fludarabine completely and we’ve still seen efficacy. Unless and until the patient is really rapidly progressive, I would in general be able to give CARs to most. Very, very old patients and very frail patients, again, I have given CARs to people in their 80s. I will say that.

Dr. Patel: 90.

Dr. Raje: I haven’t done 90s yet, Krina, but maybe. But that would be my only folks that I wouldn’t give CARs to.

Dr. Patel: Yeah, I think the one group that we … Anybody with dementia where it can worsen with the fludarabine/cyclophosphamide and everything else. Those are in terms of a medical comorbidity that we really say, “We probably shouldn’t do this” or have them get neurocognitive testing, etc., done first.

But yes, I think there are some really frail patients that maybe if they can’t tolerate fluids, those are the patients I probably wouldn’t do in case they get CRS [cytokine release syndrome] and I have to give them fluids. But I think … Agree a hundred percent for safety; if they’re rapidly progressing, not just to get them to the cells and actually get their infusion, because they end up with plasma cell leukemia and now we can’t give it to them, but more so… Again, for most of my patients where I see grade 3/4 CRS, or if I’ve seen HLH, it’s usually my patients that have rapidly progressing disease. Not that everybody will get it, but when I see it, it’s usually in those patients when there’s much more disease burden. Just to decrease the risk of that too.