Undergoing CAR T-cell Therapy

Like other forms of immunotherapy, CAR T-cell therapy is built on the basic premise that the immune system is the body’s best defense against cancer. CAR T-cell therapy transforms the immune system at the cellular level to make it a more effective fighting force.

When you undergo CAR T-cell therapy, you’re not receiving a drug. Instead, you’re receiving T-cells that have been collected from your own immune system and modified in a laboratory so they can spot and destroy cancer cells.

CAR T-cell therapy can be a long process. Your care team at Siteman Cancer Center will walk you through each step.

The CAR T-cell therapy process

There are three basic stages in CAR T-cell therapy. First, T-cells are removed from the patient’s bloodstream. Then, they are enhanced and multiplied in a laboratory. Finally, they are returned to the patient in the hospital through an IV infusion.

Before beginning CAR T-cell therapy, you will be thoroughly assessed by your care team to make sure that the treatment is right for you.

T-cell collection

T-cells, a form of white blood cell, travel throughout the body in the bloodstream. At the beginning of CAR T-cell therapy, they are collected from the patient in a procedure known as “pheresis.”

Before undergoing pheresis, you will come to the collection center to meet with a nurse practitioner. He or she will assess your state of health and make sure you aren’t taking any medications that could interfere with the collection process. You will also receive a tour of the facility to give you a better idea of what to expect.

On the day of the procedure, the patient is connected to a machine containing a centrifuge that removes T-cells from his or her blood. Anticoagulant medications are administered to keep the blood flowing smoothly. The process can take anywhere from four to six hours.

Pheresis is not painful, and most patients tolerate it well. You are able to relax in a recliner chair while the machine does its work, and you will hear a soft whirring noise as the centrifuge collects your T-cells.

Patients often pass the time by reading or watching movies. You will be given lunch, snacks, and drinks while connected to the machine, and specialist nurses periodically check in to ensure that you are comfortable. At the Pheresis Center at Barnes-Jewish Hospital, one nurse cares for no more than two patients at a time.

Pheresis usually doesn’t cause significant side effects. The anticoagulant medications lower the amount of calcium in the blood, which can lead to:

• Tingling sensations
• Chills
• Nausea
• Dizziness

To prevent these side effects as much as possible, you will be given infusions of calcium through an IV during the collection process. If you still experience discomfort, your nurses will provide TUMS, which are high in calcium, to help you feel better.

After the procedure is over, the nursing staff will check your vitals to make sure you are ready to go home. Most patients are able to leave immediately.

Modification

Your T-cells will be genetically altered in a laboratory so they can learn to attack cancer cells.

Scientists do this by inserting a gene into the T-cells that will cause them to produce a “chimeric antigen receptor,” or CAR. The CAR makes it possible for them to attach to an antigen on cancer cells and then, having done so, destroy those cells.

Most of the CARs produced to treat patients today target a particular antigen called CD-19. However, physicians and researchers are developing new forms of CAR T-cells that can detect other antigens. This will allow them to help a broader range of patients, including those who did not achieve sustained remissions after an initial round of CAR T-cell therapy.

Once your T-cells have been modified, scientists will multiply them, giving you a large cellular army to battle your cancer. By the end of the process, more than a hundred million CAR T-cells will be ready for you.

Infusion

When your new CAR T-cells are finished, you will begin a short course of chemotherapy. This takes place on an outpatient basis and should be completed in three days. The purpose of the chemotherapy is to suppress your immune system so the CAR T-cells can take hold and start working.

The dose of chemotherapy is not very high. In fact, CAR T-cells will learn their job more quickly if there are some cancer cells for them to attack, so your physicians will be careful not to administer too much chemo.

Following chemotherapy, you will be admitted to the hospital to receive your CAR T-cells. The infusion will take place in your hospital room – the bag of T-cells will be connected to your IV, and the T-cells will flow slowly into your bloodstream, where they will start multiplying and searching for cancer cells.

You will stay in the hospital for approximately two weeks after the CAR T-cell infusion so your care team can monitor you for any side effects. After you are released from the hospital, you will be required to stay in close proximity to the hospital for a period of time for additional monitoring and follow-up visits. Your care team at Siteman will help you locate temporary housing in St. Louis if you have traveled to our center from out of town.

How long does CAR T-cell therapy take?

At many cancer centers, the entire CAR T-cell therapy process usually lasts several months, starting from the collection of the T-cells and ending with the patient’s discharge from the hospital. The length of time varies depending on how quickly the T-cells can be modified in the laboratory and returned to the hospital, and how the patient’s recovery progresses after the CAR T-cell infusion.

What are the side effects of CAR T-cell therapy?

One common side effect of CAR T-cell therapy is a condition called cytokine release syndrome, or CRS. Cytokines are proteins that help the immune system do its job by triggering an inflammatory response. T-cells naturally expel cytokines as they hunt down and destroy malignant cells or germs. In many ways, CRS is a sign that a patient’s new CAR T-cells have gotten to work.

Problems can arise, however, when too many cytokines are released at once. The scale of the inflammatory response can prove harmful to patients, who may experience dangerous fluctuations in blood pressure, very high fevers, and organ failure.

Washington University Physicians are highly experienced at monitoring their patients for signs of CRS and treating it if and when it occurs. Patients will be given steroids and other medications to lower fevers, regulate blood pressure, and reverse any organ damage. Most patients make a complete recovery.

In addition to CRS, patients who undergo CAR T-cell therapy may experience a period of confusion or other cognitive difficulties.