CAR T-Cell Therapy: A Healthcare Professional's Guide - Commercialization
CAR T-Cell Therapy: A Viable Option?
Chimeric antigen receptor (CAR) T-cell therapy is the first form of gene therapy approved in the U.S. CAR T-cell therapy works with the patient's own immune system to help boost the cancer-killing effects of the T lymphocyte (T-cell), a white blood cell. It's a complicated engineering process of the T-cell. It is not a chemotherapy as traditionally used in cancer treatment.
CAR T-cell therapy is under study in patients with relapsed and refractory malignancies such as lymphomas and leukemias. The first approval, Kymriah (tisagenlecleucel) , was okayed for pediatric and young adult patients with a form of acute lymphoblastic leukemia (ALL). These very sick patients have run out of viable options for cancer treatment, which include surgery, radiation, chemotherapy, and bone marrow transplant.
The process to gather the T-cells (apheresis), attach the CAR T receptor that targets the tumor antigen via genetic engineering, and then re-infuse the cells back into the patient is a long, complex and expensive process. However, the question remains -- will these products be commercially viable and accessible by patients? How will insurance pay for these treatments? What will be the patient's responsibility in paying?
The Complexity of CAR T-Cell Therapy
Incorporating CAR T-cell therapy into routine cancer care is a major hurdle faced by manufacturers. As pointed out in AJMC, challenges to commercialization include:
- Maintaining accredited Good Manufacturing Practice (GMP) facilities for CAR T-cell manufacturing.
- Ongoing monitoring of very fragile patients.
- Shortening the manufacturing time from apheresis to eventual re-infusion to the patient, currently roughly 2.5 to 3 weeks.
- Freezing and cryogenic transportation of CAR T-cells once engineered with the CAR construct receptor.
- Ongoing education for health care providers, patients and families
Manufacturing a patient-specific product such as this is difficult to scale in order to lower production costs. However, research is ongoing to develop "off-the-shelf" or universal CAR T-cells that could reduce costs, and, even more importantly, hasten delivery to cancer patients who may have no other treatment options.
Logistics of CAR T-Cell Therapy
The timing and delivery logistics of CAR T-cell therapy could be taxing for the healthcare system:
- Academic and larger tertiary care centers are expected to be CAR T-cell centers of excellence; patients will need referral from their local oncologists to be treated at these specialized facilities.
- Travel expenses, transporation, and boarding for patients, families and other caregivers may lead to added financial hardships.
- A medical referral and insurer prior authorization process would be expected. For such a complicated and costly treatment, patients will be reviewed by payers to determine prior treatments and clinical eligibility. A quick turnaround review time will be important for these fragile patients.
- The time from apheresis, to manufacturing, to re-infusion of engineered CAR T cells back into the patient can range from 2.5 to 3 weeks; some patients may not tolerate this extended period. However, manufacturers are implementing continuous quality improvement processes to shorten this production time.
Education and Side Effects of CAR T-Cell Therapy
Education for patients, families, and health care providers will be a large component of CAR T-cell therapy. The complicated mechanism of action, manufacturing process, administration, risks, side effects, and cost issues will need to be adressed.
In this fragile and very sick patient population, serious adverse reactions such as:
- Cytokine release syndrome
- Cerebral edema
- B cell aplasia
require immediate medical attention. Nursing staff, as well as family members, must be able to recognize these dangerous complications, as there may be a delay in some side effects. However, researchers have dealt with many of these side effects in bone marrow transplant patients and are learning how to control them.
Costs and Payer Questions
A patient-specific and complicated manufacturing process such as CAR T cell development is expected to be costly. The cost of the first CAR T cell therapy from Novartis is set at $475,000 per treatment according to Novartis. Only one treatment is needed.
Specialized facilities and healthcare providers, manufacturing costs, the possible need for intensive care post-infusion due to serious adverse events, and prolonged hospitalization are costs linked with this therapy. Waht about reimbursement? Feinberg and colleagues suggest that a bundled payment approach, where a limited number of facilities offer treatment with contractual payment agreements may be one reimbursement strategy, similar to the current precedent set by allogeneic HSCT.
However difficult the therapy is, the success rate of CAR T cell therapy has been impressive in patients with refractory leukemias and lymphomas.
The commercial potential of CAR T-cell therapy could exceed $1.5 billion by 2020. Ultimately, the outcomes of CAR T cell therapy may be determined by the success of the first manufacturers to market and how well therapy is accepted into mainstream cancer care -- by patients, providers, and payers.
The Future: "Off-the-Shelf" T-Cell Therapies
Allogenic CAR T-cell production, otherwise known as "off-the-shelf" or "universal" T-cell therapy, is under investigation. Creating a universal CAR T agent could help avoid the lengthy and sometimes dangerous time period from apheresis of T cells to re-infusion, which can be weeks. Some patients are too sick to withstand this long time period until re-infusion. In fact, some patients cannot tolerate apheresis at all.
As reported by Kite Pharma in July 2016 and April 2017, they have partnered with the University of California Los Angeles (UCLA) to advance the technology needed to develop "off-the-shelf" allogenic T-cell therapies.
Research, led by Gay Crooks, MD at UCLA, involves an artificial thymic organoid (ATO) cell culture system that replicates the differentiation of T-cells ex vivo. The ATO system potentially can support the "efficient and scalable production of T-cells using pluripotent stem cell lines capable of indefinite self-renewal." Pluripotent stem cells have the ability to differentiate into many different cell types, including T-cells. In addition, technology to include chimeric antigen receptors, T-cell receptors, and other gene modifications can be incorporated into the T-cells. Kite holds the exclusive license to the ATO cell technology from UCLA.
According to Kite, the commercial-scale production of T-cells via culture in vivo have been hindered by low output of T-cells and donor-to-donor variability. However, it still remains to be seen if allogeneic "off-the-shelf" T-cell products will be as robust as autologous CAR T-cell therapies. Research in this area will continue at a fast pace.
In addition, the use of natural killer (NK) cells are under study at MD Anderson in Houston. CAR NK cell studies are targeting acute lymphoblastic leukemia, chronic lymphocytic leukemia, and non-Hodgkin lymphoma, but could potentially be used for other cancers, including solid tumors. Creating a bank of allogeneic NK cells could be an advantage for patients who cannot wait for the creation of personalized therapy from their own T-cells, and greatly lower the risk for graft-versus-host disease (GVHD) that can be seen with allogeneic T-cells.
Finished: CAR T-Cell Therapy: A Healthcare Professional's Guide - Commercialization
- National Foundation for Transplants. How much does a transplant cost? Accessed 6/6/2017 at http://www.transplants.org/faq/how-much-does-transplant-cost
- Feinberg B, Fillman J, Simoncini J, et al. CAR-T Cells: The Next Era in Immuno-Oncology. AJMC.com. Feb 14, 2017. Accessed June 1, 2017 at http://www.ajmc.com/journals/evidence-based-oncology/2017/february-2017/car-t-cells-the-next-era-in-immuno-oncology-
- American Cancer Society. Why Are Stem Cell Transplants Used as Cancer Treatment? Accessed June 3, 2017 at https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/stem-cell-transplant/why-stem-cell-transplants-are-used.html
- Kite Pharma Licenses Enabling Technology for the Development of Off-the-Shelf Allogeneic T-Cell Therapies. Press Release. Accessed June 2, 2017 at http://ir.kitepharma.com/releasedetail.cfm?releaseid=981016
- Kite Highlights Publication on Breakthrough in Generating Fully Functioning T Cells from Hematopoietic Precursor Cells by Leading Researchers at the University of California, Los Angeles (UCLA). Press Release. Accessed June 3, 2017 at http://ir.kitepharma.com/releasedetail.cfm?releaseid=1020052
- Maus M, Levine B. Chimeric antigen receptor T-cell therapy for the community oncologist. The Oncologist 2016;21:1-10. Accessed June 3, 2017 at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4861363/
- Au R. Immunooncology: Can the Right Chimeric Antigen Receptors T-Cell Design Be Made to Cure All Types of Cancers and Will It Be Covered? J Pharm (Cairo). 2017;2017:7513687. Accessed June 4, 2017 at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5292386/
- Chimeric Antigen Receptor–Directed Natural Killer Cells for B Cell Malignancies. MD Anderson Cancer Center. OncoLog, May-June 2017, Volume 62, Issue 5-6. Accessed August 10, 2017 at https://www.mdanderson.org/publications/oncolog/may-june-2017/chimeric-antigen-receptordirected-natural-killer-cells-for-b-cel.html?cmpid=linkedin_oncolog_immunotherapy_clinicaltrials_lymphoma