Skip to Navigation Skip to Search Skip to Content
Search All Centers

When Should Patients Ask About CAR T?

Read Transcript
View next

Published on April 1, 2020

Key Takeaways

  • CAR T-cell therapy for CLL is only available in clinical trials at this time.
  • Before considering CAR T, most patients will need prior treatment with one or more of the already approved frontline therapies for CLL.
  • The decision to try CAR T depends on factors like your response to prior therapies and which markers you have—consult a CLL expert for help. 

“In CLL, there would have to be a clinical trial that a patient is eligible for, and all patients have had some type of prior treatment, so certainly not for a patient for first therapy,” says Dr. Danielle Brander, explaining that while CAR T has been approved for commercial use in treating some lymphomas, it is still limited to clinical trials for CLL.

Dr. Brander, a chronic lymphocytic leukemia (CLL) expert from Duke Cancer Institute, also explains that in order to be eligible for a CAR-T clinical trial, most patients will need to have had one or more of the approved frontline therapies for CLL. This includes drugs like ibrutinib (Imbruvica), acalabrutinib (Calquence) and venetoclax (Venclexta). Watch now to learn from a CLL expert. 

Featuring

Transcript | When Should Patients Ask About CAR T?

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Andrew Schorr:                      

Those of us living with CLL know we have several approved medicines now—monoclonal antibodies, still maybe chemo for a smaller percentage of patients, and all kinds of oral therapies, either approved or coming perhaps. So, then you add to CAR T, and then you mentioned earlier transplant. So, first of all, when does the CAR-T discussion happen in that journey today for CLL patients? And does it take the place of any discussion of transplant? 

Dr. Brander:                

Right now, CLL CAR T is only available in clinical trials. So, for certain types of lymphoma, there are approved therapies that centers can almost, like, write a prescription for CAR T. But, in CLL, there would have to be a clinical trial that a patient is eligible for. And all patients have had some kind of line—some type of prior treatment. So, certainly it is not for a patient for their first therapy. 

And because of the length of time of knowing the responses and the side effect profiles of many of the approved treatments like ibrutinib (Imbruvica) or alcalabrutinib (Calquence), which are types of drugs called BTK inhibitors, or venetoclax (Venclexta), which is a type of drug called Bcl-2 inhibitors. Certainly, I think that patients will have had at least one of those prior treatments because of the known non-chemo novel targets that they have, as well as just knowing for years what the side effects and the duration that a response would be. 

It gets a little more complicated, and in a good way, to have the conversation with your treating physician of where do you fall in terms of do you consider CAR-T trials—that trial as option for you after one or two prior treatments or more like after three or four. 

And I think that’s a combination of, for example, if patients have one of these novel treatments like ibrutinib, and they have to stop that because of a side effect, that’s very different than maybe the aggressiveness of a leukemia that learns to grow through ibrutinib. So, intolerance versus resistance is a very important distinction. Certainly, I think for patients that are starting to have resistance to more than one different class of drug should be considering. Or if growing, not just intolerance, but growing through one of the classes of the compounds and having markers that are a known risk for a short growth through whatever else is available. 

There are, I should mention though for completeness, there are, of course, clinical trials besides CAR T that are looking at different targets. We’ve heard about some of these that sound very promising, but, thus far, we have less long follow-ups with those. So, to summarize a little bit, the consideration for a CAR-T trial is having a trial available, that patient would meet eligibility, patients with at least one but usually multiple lines of prior therapy. And then considering what are the markers and the likelihood to respond to whatever else is available. And recognize resistance and intolerance of the medicine, for the patient, are different things. 

The role of transplant, I would say—we keep seeing this kind of come in and out of the CLL conversation for, I think, good reason. There are many years’ experience with transplant but, historically, not only can patients have a lot of toxicity with transplant in the immediate period following, but for lifelong. So, patients can die of complications of transplant but also of things like graft-versus-host disease can significantly affect quality of life or patients can even die from that. But it can sometimes be a curative therapy. And, so, I certainly still consider in the discussions for patients. 

But one of the biggest hurdles for transplant is we know that if patients have CLL or their leukemia is actively growing, and there’s a lot of it, you can’t go right into a transplantThe transplant itself won’t knock down all that remaining growing CLL. So, often it’s not a consideration when the CLL starts progressing because if you look at all the information we have about transplant, both when we only had chemotherapy options, but even with, more recently, some groups have looked at the role of transplant in the current era which is having newer drugs like ibrutinib, alcalabrutinib, venetoclax available. 

And still, as patients, the response to the most recent treatment is that they only have a partial response or, certainly, if they’re progressing, then transplants are not going to be able to combat that. So, it’s really more a role for if you’re trying to maintain a response not trying to get a response. So, in that case, trials including CAR T to actually treat the actively growing CLL are the more appropriate conversation. 

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Recommended for You

View next