Episode 407: Pharmacology 101: CAR T-Cell Immunotherapy

“You want to try to act quickly and be able to know what the pathways are for appropriate escalating when a patient is having symptoms that are reflective of cytokine release syndrome (CRS) or neurotoxicity. These toxicities are very manageable and treatable when recognized early. To summarize, choosing the right patient, knowing the toxicity profile for each product, and acting early is really what helps to prevent severe outcomes with chimeric antigen receptor (CAR) T-cell therapy,” Maribel Pereiras, PharmD, BCPS, BCOP, clinical pharmacy specialist at the John Theurer Cancer Center at Hackensack University Medical Center in New Jersey, told Jaime Weimer, MSN, RN, AGCNS-BS, AOCNS^®, manager of oncology nursing practice at ONS, during a conversation about CAR T-cell immunotherapy.

Music Credit: “Fireflies and Stardust” by Kevin MacLeod

Licensed under Creative Commons by Attribution 3.0 

Earn 0.75 contact hours of nursing continuing professional development (NCPD) by listening to the full recording and completing an evaluation at courses.ons.org by March 20, 2027. The planners and faculty for this episode have no relevant financial relationships with ineligible companies to disclose. ONS is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

Learning outcome: Learners will report an increase in knowledge related to CAR T-Cell immunotherapy in the treatment of cancer.

Episode Notes 

• Complete this evaluation for free NCPD. 
• ONS Podcast™ episodes:
  • Pharmacology 101 series
  • Episode 267: Side-Effect Management for CAR T-Cell Therapy for Hematologic Malignancies
  • Episode 261: CAR T-Cell Therapy for Hematologic Malignancies Requires Education and Navigation
  • Episode 176: Oncologic Emergencies 101: Cytokine Release Syndrome
• ONS Voice articles:
  • A Body of Evidence Helps Nurses Manage CAR T-Cell Therapy Toxicities
  • CAR T-Cell Therapy Programs
  • Oncology Clinical Social Workers Add Layers of Support for Patients and Families During CAR T-Cell Therapy
  • Studies Show Best Practices to Manage CAR T-Cell Therapies’ irAEs and Improve Outcomes
• ONS Voice oncology drug reference sheet: Lisocabtagene Maraleucel
• Clinical Journal of Oncology Nursing articles:
  • CAR T-Cell Therapy for Relapsed/Refractory Aggressive Large B-Cell Lymphoma
  • CAR T-Cell Therapy: Updates in Nursing Management
  • Nursing Considerations in Navigating Patients Receiving CAR T-Cell Therapy
• ONS book: Guide to Cancer Immunotherapy (second edition)
• ONS Huddle Cards:
  • Chimeric Antigen Receptor T-Cell Therapy
  • Cytokine Release Syndrome
  • Immune Effector Cell–Associated Neurotoxicity Syndrome
  • Immunotherapy
• Immuno-Oncology Learning Library
• American Society of Gene and Cell Therapy: Learning Center
• American Society for Transplantation and Cellular Therapy: Learning Center
• National Comprehensive Cancer Network home page

To discuss the information in this episode with other oncology nurses, visit the ONS Communities. 

To find resources for creating an ONS Podcast club in your chapter or nursing community, visit the ONS Podcast Library.

To provide feedback or otherwise reach ONS about the podcast, email [e-mail].

Highlights From This Episode

“CAR T-cell therapy combines an adoptive cell transfer with genetic engineering. And what that really means is that we are harvesting a patient’s own T cells and then we engineer them with a synthetic receptor that helps them recognize that cancer. And all of this work has evolved through many decades of stepwise advances in how we design and activate the T cells. That led us to several landmark trials and ultimately the first CAR T-cell therapy approved by the U.S. Food and Drug Administration in 2017, which was tisagenlecleucel for pediatric and young adult patients that had acute lymphoblastic leukemia.” TS 3:34

“If a patient has higher disease burden or an inflammatory biology, that does tend to correlate with higher toxicity risk. And then that might influence the way we monitor the patients who are getting the CAR T therapy. And then finally, baseline neurologic examinations, because neurotoxicity can occur with these agents. It’s very important that we as a whole healthcare team really understand what the patient looks like at baseline to be able to determine if they’re having any altered changes or confusion. If I had to summarize it, we want to confirm the target and make sure that we have the right CAR T product for the patient. We want to confirm that the patient, physiologically and mentally, is ready for the CAR T therapy.” TS 10:53

“I think the two [toxicities] that every nurse will hear about almost immediately when talking about CAR T therapy are CRS or ICANS, which stands for immune effector cell–associated neurotoxicity syndrome. ... ICANS can either follow or even occur alongside CRS. And this can present as something as simple as just being slightly confused or altered, leading into progressively more severe elements such as word-finding difficulties, tremors, or changes in handwriting. Or even more severe cases that lead to seizures or decreased levels of consciousness. So, in this setting, neurologic assessments and knowing and understanding what your patient’s baseline neurologic status is is so important. Those are really the two largest side effects that cross the board when it comes to CAR T therapies.” TS 16:02

“In terms of the more practical aspects of administration, this is not a typical medication infusion. CAR T cells are living cells. So the way they are handled and administered is very specific. The majority of CAR T products are given as a single IV infusion. The cells come to us frozen either from a cellular lab or they will come from the pharmacy department. So those cells are typically thawed, and timing is of the essence. You really need to coordinate the timing of [thawing] to when they get infused to your patient. They tend to have a short shelf life once they’re not frozen anymore.” TS 26:34

“Now that therapy has, in many places, transitioned to be administered in the outpatient setting, education becomes absolutely critical. The patient is coming for their daily visit to clinic and then they’re going home. And it’s really up to the caregiver, who is usually not a nurse, who has to recognize early signs of toxicity. They need to be educated about what a fever is, what number constitutes a fever, what does confusion look like, what does hypotension look like? ... Do they have access to a thermometer? If you are asking them to look at blood pressure, do they have access to a blood pressure monitor? And sometimes those can be subtle things that might be overlooked. So, the emphasis in outpatient quality education is teaching those caregivers what to watch for, how to act quickly, and who to call immediately. You need to make sure that they have that information readily available if something happens.” TS 30:55