Even patients with diffuse large B-cell lymphoma who are eligible for chimeric antigen receptor (CAR) T-cell therapy face multiple barriers to care and need assistance.
Not all patients whose disease has an approved chimeric antigen receptor (CAR) T-cell therapy might be eligible for it, and even those who are eligible might face barriers to receiving the treatment, explained Christopher D’Andrea, PA-C, physician assistant in hematology oncology at the Cleveland Clinic Taussig Cancer Center.
Treating patients with CAR T-cell therapy can take a village between the professionals at the cancer center and the support system at home directly after treatment, he said.
In an interview with The American Journal of Managed Care® (AJMC®), D’Andrea also discussed the financial and time barriers to CAR T-cell therapy, as well as additional exciting advancements in the treatment of diffuse large B-cell lymphoma.
AJMC: How are providers making sure patients are informed about CAR T-cell therapy and alternate treatment options?
D’Andrea: So, as we know information is power, especially to patients who come to see us medical professionals for care. And I think it’s important to have that discussion very frankly with patients that there is something called CAR T-cell therapy that may or may not be appropriate for them. And if it's not appropriate for them, I still think it's worthwhile to mention it even if it's not going to be necessarily appropriate for patients. Because as we know a lot of times our patients can be very well informed through Google and other online outlets that can be very helpful in providing patient information.
I think it is important to discuss CAR T-cell therapy with your patients whether or not it is appropriate for them. And then to further that conversation by saying, "OK, this may or may not be appropriate for you and in the event that it is not appropriate for you, for whatever reason, that alternative therapies are considered."
I think that is one very promising facet to the treatment of diffuse large B-cell lymphoma that we have seen over the last several years is a number of alternative therapies that have been developed for relapsed and refractory disease that might be much better options for a certain group of patients that might not be eligible or simply might not fit a CAR T-cell treatment recommendation.
AJMC: The cost of CAR T-cell therapy is a major barrier to access for many patients. What programs or practices are in place to aid patients who may not be able to afford these treatments?
D’Andrea: As we know CAR T-cell therapy and a lot of therapies that we do in the cancer world can be quite expensive, and I think available to almost nobody if we're just talking about out-of-pocket expenses. I think there are a number of resources that patients can access to help get them to these treatments and not make it such a difficult thing to reach. At the Cleveland Clinic I am blessed with a ton of different resources and support staff around me as I would imagine many of the large institutions who do CAR T-cell therapy also have, as well. And this is a shout out to those people, like social workers, financial navigators, nurse care coordinators, medical assistants, and all these people that helped contribute to getting patients the care that they need.
As far as external resources, there are a few that come to mind. I know the Leukemia and Lymphoma Society, or lls.org, they do a great job about offering financial support services to patients for things like CAR T-cell and other therapies. There are other organizations out there, such as the Lymphoma Research Foundation—that's lymphoma.org—is another great resource for patients to seek financial support or other assistance in achieving and receiving these treatments. The manufacturers of these CAR T-cell products offer additional support services that you could consider contacting them. A simple Google search based on the treatment that your doctor is recommending could yield the manufacturers assistance as well.
That's just a small sample size of a few different resources that I think of for financial support for patients undergoing therapy for relapsed lymphoma and particularly CAR T-cell therapy.
AJMC: What challenges do you as a provider and your colleagues face in getting these treatments to your patients?
D’Andrea: Several challenges come to mind when you talk about getting a patient to a CAR T-cell therapy. Number one is the time in which it takes. Unlike some therapies this therapy can take several weeks, as we know, to actually get into the patient. Some patients have a history of aggressive disease that doesn't respond to therapy; therefore, their time may not be plentiful enough to get them to CAR T-cell therapy. So, time is a barrier to getting these patients to CAR T-cell therapy.
I think other logistical challenges, such as where the patient may live, how close or how far they are from our institution or a major cancer center institution that does CAR T-cell therapy. Additionally, the support that they may or may not have around them from family or friends. As we know, these patients do require a full-time caregiver in the immediate aftermath post–CAR T-cell therapy to monitor for any toxicities and side effects that come up. Some people, unfortunately, don't have that option of relying on us spouse, an adult child, a friend, or a family member to assist with that.
Those are some of the major barriers that I think of: time required to treat a patient and how aggressive their disease may be; logistical barriers, such as their proximity to the cancer center; and the need for that full-time caregiver, which I think having a full-time caregiver is quite a challenge. And in fact, I think, that's one of the major barriers for a lot of patients in my opinion.
AJMC: How are these barriers being addressed to make it easier for patients to access care?
D’Andrea: I just sort of referenced this before, but I'll say it again that it takes a multilevel layer of support around the patients. I think a lot of this is institution specific—but I'm sure it's similar throughout all institutions who are doing CAR T-cell therapy at major transplant centers—but it encompasses professionals from all disciplines, including registered nurses, care coordinators, social workers, additional support staff, case managers, things like that. I know at times we have used some of the rideshare programs who have provided rides for patients to and from appointments. That has also been helpful in some cases. But I think it's tough to say just 1 or 2, because it really does take a village to support and help these patients through this process.
AJMC: What are you working on in the management of B-cell lymphoma that you are excited to share?
D’Andrea: I think it's an exciting time as providers treating aggressive large B-cell lymphomas that in the past have been proven to be chemorefractory. It's exciting in the sense that we have more options than we did in just recent years. For me, the excitement comes from having options and seeing patients live longer and have better quality of life with some of the new treatment options.
Most recently we have seen the emergence of bispecific T-cell engagers, or the bispecific antibodies. This is another exciting new weapon in the fight against diffuse large B-cell lymphoma that is giving some patients an opportunity to not only live a better quality of life in remission but potentially longer than they would have in the only chemotherapy treatment approach as I think we've seen in years past.
With those new therapies there are additional therapies such as monoclonal antibodies or antibody drug conjugates that are now available. For those patients who may not be able to receive CAR T-cell therapy the options are much greater than they ever have been. For me, it’s an exciting time to be a part of a patient's care in the treatment of large B-cell lymphoma since we have a lot more options to help patients that we previously did not, and we're seeing benefits of those new drugs in practice every day. So, that seems to be growing and I think that is pretty exciting.