Research Summary
Chimeric antigen receptor T-cell (CAR-T) therapy is an effective treatment option for relapsed/refractory multiple myeloma (RRMM). Nurses play a crucial role in the CAR-T therapy process, not only during, but also by providing patient care before and after administration. In this study, Steinbach et al1 outlined the role of nurses in the CAR-T therapy process in the context of RRMM.
Oncology nurses should have familiarity with CAR-T therapy eligibility criteria and treatment history, as this can aid in early identification, thereby potentially preventing further disease progression. For example, ciltacabtagene autoleucel (cilta-cel) is approved in lenalidomide-refractory patients with RRMM who have received at least one prior line of therapy, including a proteasome inhibitor and an immunomodulatory agent,2 so knowledge of patient treatment history is essential before considering use of this CAR-T therapy. Furthermore, proactive authorization to avoid treatment delays and proactive determination of bridging therapies are important for optimizing outcomes. Other characteristics to consider before use of CAR-T therapy include patient health status, age, presence of neurologic conditions, use of contraceptive measures, and presence of active infection. Transportation and financial ability must also be evaluated. Patients must travel to a Risk Evaluation and Mitigation Strategy (REMS)–certified facility to receive the infusion, then remain nearby for at least four weeks following infusion; patients also cannot drive for at least eight weeks postinfusion. For these reasons, and to help in monitoring the patient for toxicities, the aid of an educated caregiver is important. Prior to treatment, patient insurance status should be established. Coverage varies, and patients should expect to have out-of-pocket costs. Nurses play a key role in communicating these considerations to patients and caregivers, as well as educating them on the treatment process, benefits, and risks of CAR-T therapy.
Nurses are involved in each step of the CAR-T therapy process, and communication between healthcare providers within and across care settings is crucial. Nurses contribute to leukapheresis, which is typically administered in the outpatient setting, by recommending individualized treatment plans, ensuring that the appropriate washout periods are followed, and educating patients and caregivers on the leukapheresis process. Following leukapheresis, bridging therapies, such as immunotherapy, chemotherapy, or radiation therapy, might be considered, particularly for patients with aggressive MM or a high risk of experiencing CAR-T therapy–related toxicities. Lymphodepletion chemotherapy is administered 5 to 7 days prior to the CAR-T infusion for three consecutive days and can be performed in inpatient or outpatient settings. Nurses should educate patients and caregivers on the necessity of lymphodepletion and potential adverse effects. It is recommended to treat patients with prophylactic antibiotics, antifungals, and antivirals following lymphodepletion and prior to infusion due to infection risk.
At REM-certified facilities, nurses typically administer CAR-T and therefore must communicate with the care team regarding equipment availability, management of side effects, timing of premedication processes, and preparation of the CAR-T cell product. Patients should be checked for active infection, and the Immune Effector Cell–associated Encephalopathy (ICE) Scale should be administered to establish a baseline for monitoring of immune effector cell–associated neurotoxicity syndrome (ICANS) following CAR-T therapy. CAR-T cell infusion must occur within 2 to 2.5 hours of thawing (or earlier), and patients must be monitored for side effects during and after infusion. Typically, CAR-T therapy is conducted in the inpatient setting, but certain patients might undergo outpatient infusion. Outpatient-specific considerations include availability of isolated infusion rooms to reduce infection risk and informing patients and caregivers of indicators of side effects that require immediate care.
Following CAR-T infusion, patients must be monitored every day for 7 to 10 days, then periodically for four weeks. Inpatient nurses must directly monitor patients, whereas outpatient nurses must educate patients and caregivers on symptom monitoring and when to seek inpatient care, as well as be prepared to readmit patients experiencing serious toxicities. Nurses should be aware of the symptoms and management of acute toxicities, such as cytokine release syndrome (CRS) and ICANS. Fever is typically the first symptom of CRS. Other symptoms include myalgia, fatigue, and hypoxia, among others. Tocilizumab should be considered for first-line treatment in those who present with fever, especially in the presence of other symptoms or in older patients or patients with severe comorbidities. Corticosteroids are another treatment option, but their long-term use might hinder CAR-T cell proliferation. Symptoms of ICANS include aphasia, cognitive impairments, tremor, and encephalopathy, among others. ICANS should be treated with supportive care, though corticosteroids can be used in severe cases. Nurses in the community setting should be aware of the signs and management of late-onset toxicities, particularly neurotoxicities. For example, movement and neurocognitive toxicity (MNT) can develop after recovery from CRS or ICANS. Some symptoms include memory loss, ataxia, and flat affect. Patients with suspected MNT should be referred to a neurologist for evaluation.
Reference
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Steinbach M, Zitella LJ, Florendo E, et al. Nursing care throughout the chimeric antigen receptor T-cell therapy process for multiple myeloma. Semin Oncol Nurs. 2023;39(6):151505.
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United States Food and Drug Administration. CARVYKTI. Current as of 31 Jul 2024. Accessed 4 Apr 2025. https://www.fda.gov/vaccines-blood-biologics/cellular-gene-therapy-products/carvykti