The advent of CAR T-cell therapy is a “game changer for blood cancers,” according to Kelly Garvin, MA, BSN, RN. However, they do have potentially lethal adverse events (AEs), highlighting the importance of specific training and education for nurses who are administering this treatment.
“CAR T-cell therapy is powerful with impressive success rates, but also with specific dangerous [adverse events] that require trained nursing staff to manage,” Garvin, a nurse at the Moffitt Cancer Center, said in a presentation at the 4th Annual School of Nursing Oncology Live, Interactive webcast.
How CAR T-Cell Therapy Works
There are currently 4 FDA-approved CAR T-cell therapies, all indicated for patients with relapsed or refractory blood cancers: axicabtagene ciloleucel (Yescarta), brexucabtagene autoleucel (Tecartus), tisagenlecleucel (Kymriah), and tocilizumab (Actemra).
The treatments work by extracting blood from a patient and programming their T cells to recognize and attack cancer cells. That process can take 10 to 14 days, according to Garvin.
“While B cells develop a very specialized affinity for specific antigens, T cells are more like professional mercenaries that go after the bad guys. And sometimes, cancer cells develop ways of hiding from the immune system escaping that surveillance,” Garvin said. “But with CAR T-cell therapy, we’re combining the specificity and the affinity of a B cell with the cytotoxic fighting ability of a T cell.”
After patients are infused with the re-engineered T cells, they typically stay in the hospital for 2 weeks or longer, Garvin explained. At this time, it is crucial for nurses to monitor for major AEs, namely cytokine release syndrome and neurotoxicity.
“These can occur quickly while the patient is still inpatient and you’re taking care of them. They occur commonly and can be deadly,” Garvin said.
Cytokine Release Syndrome
Cytokine release syndrome (CRS) commonly occurs about 2 to 3 days after a CAR T-cell infusion, but can happen as early as a few hours after. It is caused when a high amount of cytokines – an immune substance – are released into the bloodstream.
Signs of CRS include fever, chills, and rapid heart rate.
“We take vital signs at least every 4 hours on the floor and more often if we feel like something is brewing,” Garvin said. “And then after you can see that hypoxia and hypotension. [We also] monitor labs every day.”
Severe or life-threatening CRS is treated with tocilizumab, and if that does not work, steroids may also be used.
Neurotoxicity can be any number of AEs originating from the nervous system, including delirium, dysphasia, word searching, encephalopathy, and seizures. The first sign is often a headache, and nurses should also look out for a “blank look” in patients’ eyes, Garvin said.
Garvin told the story of when she realized that a patient she had been treating for 2 weeks was experiencing neurotoxicity. “I walked into [her room] 1 morning and I handed her the pill cup, and she just stared at me like she’d never seen it before,” Garvin said. “She didn’t answer any of my questions; she didn’t look at me, and then she poured her pills down her shirt. That was the first time that [I noticed] that some [neurotoxicity] was beginning to brew.”
Risk factors for neurotoxicity – which usually happens about 4 to 6 days after CAR T-cell infusion – include higher disease burden and concurrent CRS.
Treatment for neurotoxicity is often supportive care and steroids may be administered, if needed. Garvin explained that neurotoxicity and CRS both have treatment guidelines depending on what specific type of CAR T-cell therapy the patient is receiving.
Ultimately, CAR T-cell therapy is a game-changer for blood cancer, but – like every other treatment – is not perfect and comes with risks.
“We do see relapse after treatment, we see death from [adverse events],” Garvin said. “I don’t want to oversell the treatment, but what I saw is that this treatment offers the promise of hope for patients for whom traditional chemotherapy didn’t work, and their prognosis is very poor.”
Garvin, K. CAR-T Therapy: Nursing Considerations. Presented at: 4th Annual School of Nursing Oncology; July 31-August 1, 2020.