Managing the side effects of CAR T-cell therapy

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Published: 8 May 2019
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Misty Lamprecht - The Ohio State University James Cancer Hospital, Ohio, USA

Misty Lamprecht speaks to ecancer at ONS 2019 about managing the side effects of CAR T-cell therapy.

She outlines how CAR T-cells work and the role of the oncology nurse throughout treatment. She also speaks about the side effects that nurses should be aware of and how they can be managed, including cytokine release syndrome and neurotoxicity.

Misty concludes by encouraging oncology nurses to share their knowledge on dealing with these side effects.

My presentation is about CAR T-cells. To explain, CAR T-cells are chimeric antigen receptor T-cells so they’re genetically modified T-cells that are used to treat specific types of cancer currently FDA approved; others, many others, are currently being studied. My presentation actually is a joint presentation with a physician colleague who is actually from a different institution than mine. He’ll be covering more the science of exactly how the cells work. My portion of the presentation is about advanced practice providers’ management of the many side effects associated with this treatment.

Why is it important for oncology nurses to be aware of CAR T-cell therapy?

CAR T-cell therapy is so unique in that it is very targeted. There are targeted therapies out there but this one actually attacks a specific antigen on the cell surface. Unlike our conventional therapies of chemotherapy and radiation which damage a lot of other cells during their treatment of the cancer cells, this one targets only those malignant cells or cells very, very similar to those malignant cells. So in that way the patient, their normal cells go a little less scathed by the treatment.

The other very unique thing about CAR T-cell therapy is it’s referred to as a living drug. So in that way, as long as there are malignant cells there to continue to stimulate these cells, the CAR T-cells continue to replicate, make more of themselves and then continue to work on the malignancy and treating it. So it’s not dose and done.

What is the role of oncology nurses with regards to CAR T-cell therapy?

I always think the role of the oncology nurse begins with education of the patient, so educating the patients about the entire therapy. So it begins with they collect the patient’s own cells so they have to be educated on the whole apheresis procedure. Often that requires a central line so educating them on the care of their central line. Then we go to lymphodepletion chemotherapy where the patient receives significant doses of chemotherapy, has side effects associated with that, then the next step is actually getting the CAR T-cell therapy which, again, can have a lot of side effects associated with it. So the patients and their family members or the caregivers need to be familiar with those side effects and recognise those side effects, especially if they’re being treated as an outpatient.

The role more on the inpatient side for the nurses caring for these patients are to themselves recognise these side effects, the potential side effects, recognise them early, act upon those. We’re the provider’s eyes and ears at the bedside, watching those patients 24/7.

What are some of the side effects that oncology nurses need to be aware of?

The two biggest side effects that we spend a lot of time managing and require a lot of knowledge specific to CAR T-cell therapy are cytokine release syndrome. So when the cells activate they release cytokines. When the body has an overabundance of cytokines the body has adverse effects related to that. These adverse effects are very similar to sepsis so the nurse has to be aware of that, they have to know how to treat both of those two things simultaneously because the patient is at risk for sepsis as well due to the lymphodepletion chemotherapy they received. So the nurse has to be very cognisant of being able to treat both things because you don’t know which one you’re treating initially until maybe you get a blood culture back or something like that. So treating cytokine release is a big one.

The next one that usually comes after cytokine release or a little bit further down in the therapy line is neurotoxicity. This particular side effect can be very frightening for both the patient and their family. In some cases it can mimic stroke, the patient sometimes has trouble finding their words. So that’s very scary for a patient because they’re still very cognisant of what’s happening around them. If neurotoxicity progresses then it becomes more scary for the family members because they’re seeing their loved one potentially acting very strange or even becoming almost comatose. So that’s very, very scary. The nurse is integral in caring for both the patient but also providing that support to the patient’s family members as well.

What is your take home message to oncology nurses?

The biggest take home message is this therapy is so new we’re all learning together. We need each other, we need to share our knowledge with our colleagues. I think I’ve networked more, I’ve been in transplant for almost thirty years now and while we’re always learning new things this one especially has been use your friends, phone a friend, make friends, use the resources around you because we’re all learning about this therapy and the best way to care for our patients.