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
The Medstar Georgetown Stem Cell Transplant and Cellular Immunotherapy program is the only hospital in the Washington, D.C. metropolitan area to offer chimeric antigen receptor (CAR) -T cell therapy. CAR-T cell clinical trials are ongoing in the U.S. and commercially approved treatment is available.
CAR-T cell therapy involves collecting immune cells from your blood, modifying them in a lab, and returning the modified cells to you via an IV infusion. The goal is to stimulate your immune system to more effectively target cancer cells and eliminate disease.
The U.S. Food and Drug Administration has approved CAR-T cell therapy to treat adult patients with certain types of B-Cell Lymphoma that have not responded to other therapies or who have relapsed after two other kinds of treatment.
What to Expect During CAR-T Cell Therapy
At your first visit, you will meet with your care team to:
- Determine if you are an appropriate candidate to receive CAR-T cell therapy
- Discuss your treatment approach
- Discuss the CAR-T cell therapy process, potential side effects, and outcomes
- Understand the impact on your quality of life and day-to-day activities
CAR-T cell therapy begins with a process involving blood collection, to obtain immune cells needed for CAR-T cell manufacturing.
Your blood will be collected by an Apheresis machine. The machine will sort your T-cells from your blood. The non-T cells are returned to your body. This procedure can take up to six hours and is performed on an outpatient basis.
Your T cells are then sent to a lab to be genetically modified. The chimeric antigen receptor, or CAR, is attached to the T-cells. The CAR(s) grow and expand in the lab and are ready to be re-infused into your body in approximately three weeks.
During CAR-T Cell Therapy
- You will receive chemotherapy to prepare your body to receive the modified CAR-T cells. Your chemotherapy regimen may be given on an outpatient or inpatient basis.
- Your CAR-T cells will be infused back to you after receiving chemotherapy. You may be admitted to the hospital to receive CAR-T.
After receiving CAR-T cell therapy, you will be closely monitored by your care team at Medstar Georgetown. Depending on the type of CAR-T given, some patients may remain in the hospital for two weeks after their CAR-T infusion.
The biggest side effects of CAR-T cell therapy 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. If patients experience severe side effects after CAR-T cell therapy, they may 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.
After CAR-T Cell Treatment
Treatment does not end after CAR-T cell therapy. You will require monitoring over a period of years to ensure that your cancer does not come back.
You will still need to see your primary oncologist for regular monitoring and check-ups. You will continue to see your Cellular Immunotherapy care team at Medstar Georgetown.
MedStar Georgetown is an authorized Yescarta® treatment site and is an authorized site for Kymriah.
Medstar Georgetown is FACT accredited for IEC (Immune Effector Cell Therapy).
Our team multidisciplinary team is dedicated to your care. Your Cellular Therapy team care includes:
- A dedicated nurse coordinator
- A dedicated social worker
- A cellular therapy physician
- Trained and experienced nursing staff
- Financial coordinator
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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.