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Over a decade after receiving a treatment that modifies the immune cells to attack cancer, two early recipients of CAR T-cell therapy show no signs of cancer, according to a paper published Wednesday in Nature.
Infographic: Envisioning the future of cancer care
What is CAR T-cell therapy?
In CAR T-cell therapy, providers remove a type of immune cell called T cells from a patient's blood, genetically modify them with receptors that target and destroy cancer cells, and then infuse the T cells back into the patient's blood. According to the New York Times, these therapies are promising treatments for certain cancers, but they do pose serious side effects—including cytokine release syndrome, neurological effects, high fevers, comas, dangerously low blood pressure, and even death. That said, these more severe symptoms have dissipated in most patients, the Times reports.
Notably, the treatment does not work for all patients or all cancers. For instance, the treatment has not yet worked in patients who have solid tumors, such as the ones found in individuals with breast or prostate cancer.
So far, FDA has approved CAR T-cell therapies to treat several types of leukemia and lymphoma, as well as multiple myeloma, and clinical trials are ongoing for a range of other cancers, Axios reports.
CAR T-cell therapy may provide a 'cure' for some cancer patients
In 2010, three patients with chronic lymphocytic leukemia (CLL)—a cancer that starts in the bone marrow and slowly progresses to the blood—received CAR T-cell therapy at the University of Pennsylvania as part of a clinical trial to evaluate the treatment's safety and effectiveness.
When the trial began, the idea for this treatment "was way out there," according to Carl June, the principal investigator for the trial. In fact, June's own expectations for the survival rate of the T cells they were providing to patients in the trail were relatively low. "We thought they would be gone in a month or two," he said.
However, in a paper published Wednesday in Nature, June and his colleagues reported that two of the three trial participants, Doug Olson and William Ludwig, went into a remission within a year of the initial treatment—and neither Olson nor Ludwig had any sign of cancer over the subsequent 10 years. (Notably, Ludwig passed away in 2021 from Covid-19.)
For the treatment used in the trial, researchers genetically modified a subset of T cells called CD8 cells—known as "the assassins of the immune system," according to the Times—that get help from another group of T cells called as CD4 cells.
Initially, researchers noted that these modified CD8 T cells almost immediately killed between three and a half and seven pounds of cancer cells in Ludwig's and Olson's bodies. Unexpectedly, however, the researchers observed that the CD8 cells remained in the patients' blood after attacking the patients' cancer cells and turned into CD4 cells—cells that in subsequent laboratory tests were able to kill B cells.
As John DiPersio, chief of the division of oncology at Washington University in St. Louis, who was not involved in the study, put it, these CD4 cells had surprisingly turned into assassin cells themselves or, "at least guardians that can keep the tumor cells at bay and undetectable in the patient for years."
Separately, June said Olson has no detectable leukemia cells. He noted that while leukemia cells may linger in Olson's body in very small quantities, only to be knocked back by CD4 cells "like whack-a-mole," he believes that "[t]he leukemia is gone" and the CD4 cells are just "stay[ing] on the job."
June added, "We need many more patients to be followed but at least in these two patients there is no more leukemia."
Not a cure-all for CLL, experts say
While enthused by Olson's experience, David Porter—Olson's oncologist at the University of Pennsylvania—cautioned that the therapy is not a cure-all for everyone with CLL.
Olson's results are "beyond my wildest imagination," Porter said. "Oncologists don't use words like 'cure' lightly or easily or, frankly, very often. I guarantee that it's not being used lightly. The patients we treated had far advanced disease."
That said, he added that "the biggest disappointment is that it doesn't work all the time."
In fact, according to the Times, among patients like Olson who have CLL, the treatment has historically been less successful. Roughly a third to a fifth of CLL patients have gone into remission with CAR T therapy, but many have had their cancer relapse—even after it disappeared completely.
"The question is not only why some patients relapse or are resistant to therapy but why are some patients cured?" said DiPersio.
Total cost of CAR T-cell therapy can exceed $1 million
In a separate study by Prime Therapeutics, researchers analyzed real-world data and found that the total cost of CAR T-cell therapies averages more than $700,000 and, in some cases, can total more than $1 million.
For the study, researchers over two and a half years analyzed 74 patients who received treatment for B-cell lymphoma. First, they performed an assessment to evaluate treatment episode costs starting 30 days before the treatments were administered. Then, they evaluated post-treatment clinical outcomes starting 56 days after the treatments were administered.
Throughout the initial treatment period, the study found that the total cost of care ranged from $350,000 to more than $2 million. The cost for CAR T treatment medication alone averaged $527,000—making up approximately 74% of the total cost during the initial treatment. However, researchers found that 12% of patients with post-CAR T events incurred a total cost of over $1 million.
"CAR T-therapies represent an incredible advancement in treating B-cell cancers," said Joseph Leach, SVP and CMO for Prime Therapeutics. "Given the cost and toxicity of these treatments, we need better information to understand who derives durable benefit as well as how to best treat those who progress following therapy." (Snyder, Axios, 2/2; Kolata, New York Times, 2/2; Antrim, Pharmacy Times, 4/13/2021)
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The way cancer programs deliver and are reimbursed for care is rapidly changing. Check out our infographic to hear oncology leader's take on where cancer care is headed in the next decade.
The 4 biggest questions we have about CAR T-cell therapy
By Lindsey Paul and Deirdre Saulet
Since the first patients received CAR T-cell therapy over ten years ago, the pipeline has continued to demonstrate impressive results, with multiple new approvals in just the past year. As the long-term curative potential of CAR T becomes even clearer, here are the questions we'll be looking to answer:
Which patients might benefit?
Despite the cures that CAR T can produce, we know that a significant portion of patients still relapse following treatment. Current research into identifying patients that will respond best could enable better targeting of CAR T-cell therapy in the near future. In the meantime, it is crucial to guide patient expectations, especially as more stories about "cured" patients make headlines. Managing patient expectations will be particularly important in the context of our next question:
How will we ensure equitable patient access?
CAR T treatments are now available at over 150 sites around the country, a substantial improvement since the first indication was approved in 2017. But it can still be difficult for rural patients to access treatment, especially since CAR T-cell therapy often involves lengthy hospital admissions and more than a third of patients must travel at least 50 miles to the nearest center. Furthermore, the cost of CAR T-cell therapy and associated care can make it unaffordable for under-insured or uninsured patients. Whether we can ensure accessibility for these patients will depend on how the following question plays out:
Will CAR T become more affordable?
In the current payment landscape, some providers have found that reimbursement does not fully cover the cost of providing CAR T to patients not enrolled in clinical trials. However, research advancements could make CAR T more affordable for patients and providers. For example, better control of adverse events is enabling CAR T administration in the outpatient setting, where costs are lower and reimbursement tends to be higher. In addition, growing evidence of the long-term success of CAR T may make health plans more open to greater coverage or to testing out new payment models, such as outcomes-based contracts. Finally, it is possible that eliminating the need to harvest cancer patients' own T-cells with "off-the-shelf" CAR T products may lower treatment prices and expenses. We will be keeping an eye on these advancements over the next few years, along with our final question:
What will the future of CAR T utilization look like?
Although CAR T is mainly used as a last resort for cancer patients with certain hematologic indications, mounting evidence of its benefit is bringing CAR T into earlier lines of treatment. Recent positive clinical trial results in 2nd-line lymphoma could substantially increase the number of eligible patients, with an FDA decision on expanded approval forthcoming. Beyond that, we will be watching to see whether current successes can be translated into cell therapies for solid tumors, which would have significant implications for cancer patients, providers, and the larger health care system. Expanded patient eligibility would necessitate much greater capacity for both CAR T manufacturing and administration, and we are interested to see how manufacturers, providers, and payers respond to these developments as they occur.
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