Hollings hematologist helps to write expert panel opinion outlining best practices for outpatient CAR-T-cell therapy

Outpatient cancer care tends to be preferred over inpatient care by doctors and patients alike, for reasons that span comfort, cost and even lower likelihood of infections. Some treatments, however, need to be performed on an inpatient basis because of the length of treatment or the high chance of severe side effects.

At its debut, chimeric antigen receptor T-cell (CAR-T) therapy was one such treatment. In CAR-T-cell therapy, the patient’s own T-cells are removed from the bloodstream, reengineered in a lab to target a protein on the cancer cells infecting the patient and multiplied into millions of copies and then returned to the patient as CAR-T-cells to fight the cancer. These reengineered cells are effective – but they can also cause an overreaction in the body’s immune system, leading to neurological side effects or cytokine release syndrome.

However, some cancer centers, including MUSC Hollings Cancer Center, have begun providing CAR-T-cell therapy in an outpatient setting to carefully selected patients. As interest in outpatient CAR-T-cell therapy has grown, so has the need for guidelines for best practices.

In November, the American Society for Transplantation and Cellular Therapy published an expert panel opinion by 15 experts from across the country, including Hollings hematologist-oncologist Hamza Hashmi, M.D., outlining considerations for hospitals planning an outpatient program.

“With the growing use of CAR-T-cell therapy and the need to give it on an outpatient basis with all the benefits that you can reap – avoiding hospital stays, the cost of therapy, freeing up hospital beds for other patients – there was a need to have practice guidelines compiled by the American Society for Transplantation and Cellular Therapy and circulated so that smaller and medium-sized centers could learn from the experience of bigger centers,” Hashmi explained. “This Committee on Practice Guidelines works on important aspects of transplant guidance and comes up with these guidelines related to patient care and management.”

“With the growing use of CAR-T-cell therapy and the need to give it on an outpatient basis with all the benefits that you can reap – avoiding hospital stays, the cost of therapy, freeing up hospital beds for other patients – there was a need to have practice guidelines compiled by the American Society for Transplantation and Cellular Therapy and circulated so that smaller and medium-sized centers could learn from the experience of bigger centers."

Hamza Hashmi, M.D.

Hashmi noted that patient selection is an important factor in deciding whether to provide CAR-T-cell therapy on an outpatient basis. There are six CAR-T-cell therapies approved by the Food and Drug Administration to treat different leukemias, lymphomas and multiple myeloma. People who can undergo the treatment on an outpatient basis are usually younger, in better physical condition, have fewer cancer cells in their systems and are slated to receive a CAR-T-cell therapy that usually produces fewer side effects.

Even so, these patients and their caregivers must devote a significant amount of time to the therapy.

“They have a 24/7 caregiver, and we train and educate the caregiver very well,” Hashmi said. “They come to the cancer center every day. In case they need help at times when they are not at the cancer center, they have direct access to a physician line and a hospital bed available for admission and early interventions.”

Hollings CAR-T patients who need to be admitted on an emergency basis are received by an inpatient team familiar with the effects of CAR-T-cell therapy, rather than needing to go through the Emergency Department.

That type of planning requires coordination and cooperation among different departments and multiple levels of hospital administration, something that is important for cancer centers to consider as they move toward offering outpatient CAR-T-cell therapy. Departments across the system, including social work, nursing, billing and administration, must work together.

“It’s a team play,” Hashmi said. “It’s a very comprehensive care team with multiple players.”

The side effects of the current generation of CAR-T-cell therapies mean that most patients will eventually be hospitalized. Hollings researchers are currently working on a trial of purified CAR-T-cells that should create fewer side effects.

However, even knowing that they may end up in the hospital, most patients seem to appreciate the chance to receive the therapy on an outpatient basis and to stay out of the hospital for as long as possible, Hashmi said.

“The familiar environment with the caregiver can be somewhat comforting physically and psychologically, so patients appreciate that experience, despite the fact that the majority of these patients do end up having fevers a few days later and may need to be admitted,” Hashmi said.

Related Links

More MUSC Hollings Cancer Center news

Subscribe to our newsletter

Hollings Horizons magazine