Integrating CAR T-Cell Therapy Into Community Oncology Practices

Community oncology practices come in all shapes and sizes with larger centers often having more resources to provide patients with. The same goes for chimeric antigen receptor (CAR) T-cell therapies and their availability in larger oncology centers vs the smaller ones.

There is anincreasing use of CAR T-cell therapies being seen as they make an entrance as a potential second-line therapy in different patient populations.

According to Peter A. McSweeney, MD, the larger community oncology centers typically can administer CAR T-cell therapy the same way or similarly to how it is done in academic centers. However, in smaller community practices, the resources for administering CAR T-cell therapy are not always available, and usually requires a referral to an academic center.

McSweeney also notes that administering CAR T cells in the community setting can be challenging as oncologists need the proper expertise and infrastructure to do so properly.

“The biggest challenges for administering these CAR T cells in the community are developing a program that has the appropriate expertise and infrastructure for this type of work. It's a very multifaceted type of therapy that draws on inpatient and outpatient arrangements that meet the needs of the patients. Also, there is a need for subspecialty support in the hospital for patients who have complications with the therapy,” stated McSweeney, hematologist/oncologist at the Colorado Blood Cancer Institute, in an interview with Targeted Oncology^TM.

In the interview, McSweeney discussed the ways in which community oncology centers are implementing CAR T-cell therapy into their practice and the challenges that come with it.

Targeted Oncology: How are community practices handling the logistics of administering CAR T-cell therapies and the RMS requirements associated with CAR T use?

McSweeney: Community practices come in different types. There are some quite large community malignancy programs, which are clinically the equivalent of academic centers. They handle all this pretty much according to the same algorithms as the academic centers. The issue of smaller oncology practices in this area is not an issue right now. There’s been very little penetration of CAR T-cell therapy, and these types of cellular therapies to those practices, although they are subtly showing interest in trying to develop capability.

What are the biggest challenges with administering CAR T-cell therapy in community practices?

The biggest challenge for administering these CAR T cells in the community is developing a program that has the appropriate expertise and infrastructure for this type of work. It's a very multifaceted type of therapy, it draws on inpatient and outpatient arrangements that meet the needs of the patients, and there is a need for subspecialty support in the hospital for patients who have complications with the therapy.

Now that CAR T cells are entering the second-line for some cancers, how does this change how community practices may choose treatments for patients?

What I think is very important for second-line therapy is that the community practice is aware of these changes because patients are now moving into this as the therapy at first relapse, or at least incorporate this into the treatment strategy at first relapse, so one needs to know this. In some instances, the timing of therapy and the urgency of referral is a big issue. The physicians in the community who are not administering this therapy need to be aware and get the patient referred quickly to the appropriate places, particularly for diseases like diffuse large B-cell lymphoma in initial relapse or that is resistant to primary therapy.

What is your advice on when to give CAR T-cell therapy in a second-line setting?

The administration of CAR T-cell therapy in the second-line is disease dependent. It is indicated now for either initial resistance of diffuse large B-cell lymphoma or relapse diffuse large B-cell lymphoma in the first year after treatment. That is the aggressive B cell lymphomas. That's the main setting for second-line therapy. It can also be employed in B-cell acute lymphoblastic leukemia, mantle cell lymphoma, and select patients in the second-line.

How are community practices addressing and/or preventing toxicities seen with CAR T cells or bispecific antibodies?

The use of CAR T cells and bi-specific molecules can generate cytokine release syndrome and neurotoxicity, which are unique side effects that are not generally encountered in the general oncology setting. These are sort of specialized problems. There are some community hematologic malignancy programs that deal with these routinely. But in general, these are not going to be in the domain of the general oncologist.

When would you recommend referring a patient to an academic center for CAR T administration or to manage the toxicities for CAR T cells?

I think the academic centers play a big role in this. There are other very well-developed malignancy centers that provide equivalent sort of services. But if you're a general oncologist, you must be referring patients with the appropriate diseases to those centers. You are not going to try to take this on yourself. A lot of the toxicities that have to do with CAR T-cells and bispecifics are closely related to their administration, so they're not really falling under the jurisdiction of the general oncologist. There are late adverse events however, that remain for general oncologists as patients transition back to these doctors.

How comfortable are community practices when it comes to administering therapies like CAR T Cells and bispecific antibodies?

Community practices will only be comfortable administering these types of therapies if they have the appropriate infrastructure and have physicians who are experienced with managing them. For community oncologists or oncology networks, to think about managing these patients, they have to drill down on what they need to put in place. They're not going to be at all comfortable trying to manage these patients until I've tackled that issue.