If you have diffuse large B-cell lymphoma (DLBCL), a new treatment called CAR T-cell therapy might be just the answer you’ve been looking for.
But is it the right treatment for you?
What Is It?
It’s a type of immunotherapy. That means it works with your body’s immune system. CAR T-cell therapy uses modified versions of a type of your body’s white blood cells -- the T cells -- that are able to target and destroy cancer cells.
“This is truly a new generation of medication that we never had. It’s a living medication. It’s personalized medication. It’s your own self,” says Rabi Hanna, chairman of the Department of Hematology-Oncology and Bone Marrow Transplant at Cleveland Clinic Children’s.
“Right now, we are learning how to get it better.”
How Does It Work?
Doctors draw blood, separate the T cells, and send them to a lab. (They put the rest of your blood back in.) At the lab, the T cells are infused with genes that give the cells chimeric antigen receptors, or CARs, designed to track down and destroy certain cancers.
The new T cells are multiplied in the lab until millions of them are ready to do their work. Before these new cancer fighters are put back into your bloodstream, you'll get chemotherapy to make room for them. Once back in your body, the new T cells seek out and destroy the cancer. They can multiply further, and they may guard against any relapses.
Can I Get It?
CAR T-cell therapy has worked against some types of blood cancer. But it doesn't work for everybody, and it's not available to everyone.
In October of 2017, the FDA approved a drug, axicabtagene ciloleucel (Yescarta), for people with certain types of large B-cell lymphomas, including DLBCL. The FDA approval applies only to people “who have not responded to or who have relapsed after at least two other kinds of treatment.”
“We don’t do it upfront for everybody," Hanna says. "We only do it for [people] who prove their disease is really tough and life-threatening.”
The reason it’s limited to those people is simple: CAR T-cell therapy is not without risks.
What Are the Risks?
CAR T-cell therapy has some serious, possibly life-threatening side effects. Those potential dangers, though, need to be weighed against any other choices you may have. Often, those choices are limited.
“If the question is, are there toxicities associated with CAR T cell, the answer is yes," says Renier Brentjens, the director of cellular therapeutics at the Memorial Sloan Kettering Cancer Center. "But for the most part, if they’re properly managed, they can be fully reversible.”
When the CAR T cells are put into the body, your immune system responds, as expected, much like when you’re sick with the flu and your white blood cells attack the virus.
One such response with CAR T-cell therapy is a condition called cytokine release syndrome (CRS). This is when immune substances called cytokines cause things like:
- Rapid heartbeat
- Low blood pressure
- Trouble breathing
Those side effects can be serious, even life-threatening.
Brentjens says those treated with CAR T-cell therapy also can have some neurological problems that include seizures or confusion. But “virtually all of these [people] ultimately recover,” he says.
Does It Work?
Those who fight cancer on a daily basis are excited about this therapy because the early results, especially for those with DLBCL, have been so positive.
“From work that we’ve done in adults, the complete remission rate in treated [people] is extremely high” says Brentjens. In fact, it's above 50%
“Without using the ‘C’ word [cure], we have folks that are 5, 6 years out from CAR T-cell therapy that are alive and kicking."
That means many more folks are achieving remission who may not have before.
What Else Should I Know?
It’s expensive. Hanna says the CAR T-cell drug for DLBCL is about $375,000.
“This is just for the product itself,” Hanna says. “That doesn’t count the hospitalization that could include an intensive care unit, so this easily could go up another couple hundred thousand dollars.”
Help is available for some to defray the costs. But those who are considering CAR T-cell therapy should know, going in, that the costs will be high. Talk to your doctor and insurance company.
“You need to make sure that this can be reimbursed," Brentjens says. "This is expensive therapy. I suspect the cost will come down over time, but as it stands, it’s expensive therapy.”
Not everyone does it. As a result, you'd need to go to a certified health center that can perform CAR T-cell therapy. That could involve travel.
You'd also have to stay close by throughout the second part of the process, which includes:
- The chemotherapy
- The injection of the CAR T cells
- A hospital stay of a week or so and weeks of follow-up.
Altogether, that could be a period of maybe 2 months, Hanna estimates. If you live away from one of the few dozen centers, that could be a problem.
“Right now, It’s so important that you find a center that has as much experience as possible with this,” Brentjens says. “This may become routine and mundane as a form of therapy 5 years from now. But currently, you want to go to a place that has highly trained physicians and nursing -- especially nursing -- because there are toxicities associated with this."
So Now What?
Brentjens sees a time, perhaps in the 5- to 10-year range, when CAR T-cell therapy becomes much safer and more effective; so much so that it can be given in hospitals and clinics rather than special centers.
With that, the cost of the treatment is expected to go down significantly. Researchers are now looking at a kind of “off-the-shelf” drug that would take a “generic” T cell, rather than a personal one, to fight off cancer, Hanna says. That would lower the price even more.
“I think immunotherapy is a very exciting new area that is showing some very successful results,” says Steven Rosenberg, MD, PhD, chief of surgery at the Center for Cancer Research.