CAR-T Cell Therapy for Non-Hodgkin Lymphoma: The Story of Daisy Diggs
Daisy Diggs of Maryland received CAR-T cell therapy for non-Hodgkin lymphoma as part of a clinical trial through Georgetown Lombardi and MedStar Georgetown. Meet Daisy and learn about the study and the therapy that led to Daisy’s remission.
Autologous stem cell transplant involves using your own stem cells after receiving high-dose chemotherapy to fight your cancer. The stem cells are collected by a process called Apheresis, which is performed in the Apheresis unit of the hospital. In most cases, stem cell collection is an outpatient procedure. After stem cells are collected, they are processed and you go home to rest for a week before your hospital admission to receive an autologous stem cell transplant. On the first day of your admission, you will begin a high dose chemotherapy regimen. Depending on the type of treatment prescribed for you, you will receive your transplant after the chemotherapy is completed. Autologous stem cell transplant involves the infusion of cells, much like a blood transfusion.
It is not a surgical procedure. Typically, most patients are in the hospital 7-12 days following their autologous stem cell transplant infusion. After receiving high-dose chemotherapy and the stem cell infusion, you are very vulnerable to infection. It’s important to take precautions to protect your immune system like limiting visitors and exposure to anyone with illness. At this point in time, the stem cells are regrowing in your body and strengthening your immune system. Your transplant physician will determine if your stem cells have regrown to a satisfactory level and if it is safe for you to leave the hospital. You will continue to have close follow up in our clinic on 2E at MedStar Georgetown.
Unlike autologous transplant, allogeneic transplant involves finding a suitable donor to collect stem cell from for your transplant. The donor may be a family member or someone from a national bone marrow registry. In any case, a search will be conducted to find the person who most closely matches your own DNA. This is usually done through blood testing and is called HLA typing.
Sibling/Family Member Donors
If blood testing reveals that your family member is the best match, then you will move forward with a family member allogeneic transplant. We call this type of stem cell transplant “matched related”. If your family member is agreeable, we will move forward with testing this person to ensure that they are suitable to donate stem cells. Your family member will be evaluated by a different physician at Georgetown and will undergo a physical exam and blood testing. They must be healthy enough to donate stem cells for you. Any abnormal results will be reported to your transplant physician and a decision will be made on whether or not to proceed forward. If no abnormal results are found, the allogeneic transplant will move ahead as planned. It’s important to note that your donor has to agree to donate stem cells or bone marrow for your transplant.
A haploidentical transplant is another type of allogeneic transplant. It involves receiving donor stem cells from a half-matched family member. Haploidentical donors can be parents, children, and siblings of the patient. Parents are always a half-match for their children. Siblings (brothers or sisters) have a 50% (1 out of 2) chance of being a half-match for each other. It’s very unlikely that other family members (like cousins, aunts or uncles) would be a half-match. Haploidentical transplants are a great alternative when a fully matched family member cannot be identified.
In most cases, haploidentical transplants can be performed more quickly than waiting for a matched related transplant from the bone marrow registry. A patient’s half-matched family members can serve as a readily available resource for patients needing an allogeneic transplant. This is important when treating blood cancers that have an increased risk of relapse while waiting for a donor to become available. For both donors and patients, the procedure for a haploidentical transplant is very similar to an allogeneic transplant. The main difference is that haploidentical transplant patients will receive high dose chemotherapy several days after their transplant. Receiving high dose chemotherapy after the transplant can help to reduce or prevent the occurrence of Graft vs. Host disease, a common side effect of allogeneic transplant.
Haploidentical transplant has similar success rates to conventional allogeneic transplant.
If blood testing reveals that you do not have a suitable sibling or family member match, finding a donor from the bone marrow registry may be the best choice. We will conduct a thorough search to ensure that we find a donor that closely matches your DNA. Once the donor is found, they are evaluated through the registry to ensure that they are in good health and able to donate stem cells or bone marrow for your transplant. The process is completely anonymous, and you will not be given any personal information about your donor. You may be given the option to meet them at a later point in time after your transplant, if that is something that you would like to do. It’s important to note that the donor must agree to donate stem cells for you.
After the donor is selected, your transplant evaluation is scheduled. You will undergo blood testing and evaluation to ensure that you are well enough to receive an allogeneic transplant. Unlike autologous transplants, allogeneic transplants carry the potential risk of your body rejecting the donor stem cells. Throughout your life, you will continuously be monitored for signs and symptoms of this condition. This condition is called Graft vs. Host Disease.
You will be admitted to the hospital in preparation to receive your allogeneic transplant. You will receive high dose chemotherapy and may or may not receive irradiation before you receive your donor stem cells. The high dose chemotherapy and irradiation get rid of any residual disease and make room in the bone marrow for the new donor cells.
You may also receive other medications and antibiotics that are new to you. Some of the medications are designed to prevent your body from rejecting the new stem cells. Some of the medications are to protect your immune system while it is most vulnerable. An example of this is prophylactic antibiotics-they are given to prevent potential infections.
The donor cells take time to grow in the body. The period of stem cell regrowth is called “engraftment”. You will not be able to go home from the hospital until you have engrafted. The expected period of time you will be in the hospital is estimated to be 14-28 days.
After your allogeneic transplant, you will be seen in the 2E outpatient clinic at MedStar Georgetown. You will be monitored closely by the transplant physician and clinical team.
CAR-T Cell Therapy
Car-T cell therapy is a new, innovative therapy that is used to directly target tumors. CAR-T cells are unique from chemotherapy. They can stay in the body for years and continue to circulate and kill cancer cells.
Much like autologous stem cell transplant, patients collect their own T-cells through a process called Apheresis. The T-cells are removed and shipped to a processing lab for manufacturing. In the lab, a special tumor fighting antigen is attached to the T-cells. This manufacturing process can range from 14 days to one month.
In preparation for CAR-T, you will receive chemotherapy to make room in your body for the new T-cells. This chemotherapy may be given inpatient or outpatient.
After you have received chemotherapy, you will receive the CAR-T infusion. The infusion can be performed either inpatient or outpatient, dependent on your diagnosis and type of CAR-T therapy prescribed. The infusion takes about an hour and you’ll be closely monitored for several hours afterwards.
The biggest side effects of CAR-T include the development of Cytokine release syndrome (CRS) and neurotoxicities. CRS syndrome means that your body is setting up an immune response and substances called cytokines are released. Signs of CRS include lowered blood pressure, fever, rash, chills and abnormal laboratory values. Some patients will require care in an intensive care unit (ICU).
Neurotoxicity signs include dizziness, forgetfulness, and seizures. Some patients may experience difficulty in speaking or writing. Your doctor and clinical team will monitor you carefully for abnormal symptoms and signs of neurotoxicity.
Treatment does not end after CAR-T therapy. You will require monitoring over a period of years to ensure that your cancer does not come back. You may require more CAR-T cell infusions or additional chemotherapy.
MedStar Georgetown is an authorized Yescarta® treatment site.
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Awards & Recognitions
MedStar Georgetown Awarded FACT Accreditation
Our program, home to the nation’s largest stem cell collection facility, is the region’s only adult, Foundation for the Accreditation of Cellular Therapy (FACT)-accredited program for autologous transplant, allogeneic transplant, and cellular immunotherapy. Learn more.