Meeting Coverage
ASH: Hematology
By
Charles Bankhead, Senior Editor, MedPage Today
December 10, 2023
SAN DIEGO — Autologous stem-cell transplantation (ASCT) led to improved outcomes as compared with CAR T-cell therapy for patients with relapsed large B-cell lymphoma (LBCL) in complete remission, a retrospective analysis showed.
Patients who underwent ASCT had fewer relapses at 2 years (27.8% vs 48.0%) and better progression-free survival (PFS, 66.2% vs 47.8%), and overall survival (OS, 78.9% vs 65.6%). In the subgroup of patients with early treatment failure, ASCT was associated with a lower 2-year relapse rate (22.8% vs 45.9%). Treatment-related mortality did not differ between the two types of treatment.
By multivariate analysis, CAR T-cell therapy was associated with a higher risk of relapse and inferior PFS, reported Mazyar Shadman, MD, of the University of Washington and Fred Hutchinson Cancer Center in Seattle, at the American Society of Hematology (ASH) meeting.
“The message here is that this data could be practice informing and confirming,” Shadman said during an ASH press briefing. “In patients who relapse after first-line therapy after 12 months, the current standard of care is salvage therapy with autotransplant. This data confirms that. There’s currently no data suggesting that patients who are in CR [complete remission] should receive CAR-T therapy in that setting.”
“The goal of therapy should be CAR-T therapy, and all efforts should be made to improve access to CAR-T,” he continued. “Until then, for patients who achieve a good clinical response, an autotransplant [ASCT] strategy could be a reasonable option to discuss … and could add another potentially curative therapy for these patients, knowing that CAR-T could still be utilized in the later line of therapy if autotransplant fails the patient.”
LBCL in CR
During a discussion that followed the presentation, Shadman emphasized that the study involved patients who were in CR after initial relapse. Patients referred for CAR T-cell therapy often receive chemotherapy during the interval when cells are being processed for infusion.
“We don’t expect these patients to respond to subsequent chemotherapy because they have already shown that they don’t do well with chemotherapy,” he said. “However, some do. Sometimes we see after one or two cycles of chemotherapy, their disease goes away. They’re in complete remission.
“The [situation raises] a practical question. This patient has very chemo-sensitive disease. We know that they do well with autotransplant, so what do we do now? Still send them for CAR-T? Maybe try autotransplant because we know they can be cured with autotransplant, and if autotransplant doesn’t work, you still have CAR-T as your backup plan.”
For patients with primary refractory disease, CAR T-cell therapy is the treatment of choice in second line.
“We are not suggesting that these patients should be sent for autotransplant,” said Shadman.
The discussion led to comments about the FDA’s recent safety communication regarding a potential risk of secondary malignancies with CAR T-cell therapy.