Outcomes have improved in recent years for patients with B-cell malignancies such as diffuse large B-cell lymphoma and B-cell acute lymphoblastic leukemia (ALL), but many patients continue to develop relapsed or refractory disease. In this interview with i3 Health, Stephanie Jackson, MSN, RN, AOCNS®, BMTCN®, Oncology Clinical Nurse Specialist at the Ronald Reagan UCLA Medical Center, discusses advances in chimeric antigen receptor (CAR) T-cell therapy, which has been shown to produce significant antitumor response in B-cell malignancies.
What led you to work with patients with B-cell malignancies?
Stephanie Jackson, MSN, RN, AOCNS®, BMTCN®: Working in oncology has always been a desire of mine ever since the beginning of my nursing career. Throughout my undergraduate studies, I sought to understand the complexities of the immune system and the etiology of cancer development. Once I received my first job as a nurse working with hematology and clinical trial patients, that experience further validated my desire to continue obtaining knowledge in order to be the best I could be for my patients and their families.
How have the prospects changed for patients with B-cell malignancies since you first began working with this population?
Ms. Jackson: When I began working with B-cell malignancy patients, we had limited options for treatment, and many patients would succumb to their illness due to relapse or nosocomial infections. Patients with pre–B-cell ALL received standard hyper-CVAD (cyclophosphamide/vincristine/doxorubicin/dexamethasone), and if they were not transplanted, their options for treatment were dismal. In 2009, a retrospective study was conducted among patients aged 19 to 70 to evaluate the efficacy of the augmented Berlin-Frankfurt-Munster regimen, which had previously only been used in the pediatric setting. Complete remission was achieved in 93% of patients. This is just one example of the evolution of treatment that has added to the survival of patients with B-cell malignancies at a level not previously witnessed in clinical practice.
What do you feel are the most important advances in the area of CAR T-cell therapy?
Ms. Jackson: New developments in the area of CAR T-cell therapy include enhancing the selectivity of the antigen receptor as well as controlling its activity. The first generation of CAR T-cell therapy was designed to provide direct antigen recognition, which allowed the T cells to be activated. These cells had limited ability to expand; therefore many succumbed to apoptosis. The second generation of CAR T-cell therapy added an intracellular co-stimulatory domain. The third generation has multiple co-stimulatory domains, causing greater cytotoxic activity.
How do you predict that the treatment of B-cell malignancies will evolve in the future?
Ms. Jackson: The future of treating B-cell malignancies will include an increased number of patients receiving stem cell transplantation after CAR T-cell therapy. Studies are currently underway to evaluate reducing the prevalence of relapse; researchers are also developing combined allogeneic CAR T-cells. Additional multicenter trials will occur to evaluate the impact of CAR T-cell therapy on patients who receive stem cell transplantation and the use of stem cell transplantation in reducing relapse as standard of care.
Further evolutions include clinical trials expanding the use of CAR T-cell therapy to include patients with multiple myeloma, acute myelogenous leukemia, and chronic lymphocytic leukemia.
What advice do you have for oncology nurses working with patients with B-cell malignancies?
Ms. Jackson: Oncology nurses must elicit every opportunity to enhance their competencies in caring for patients with B-cell malignancies. As the complexity of treating hematologic malignancies continues to increase with advances in the field, it is essential that nurses stay current with their knowledge in order to optimize the quality and safety of care.
For More Information
For additional expert perspectives from Ms. Jackson and from Leslie Smith, RN, APRN-CNS, AOCNS®, complete i3 Health's complimentary Online Strategy Session for CE credit and ILNA points: Understanding and Optimizing CAR T-Cell Therapy for Patients With B-Cell Malignancies
Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily represent the views of i3 Health.