Optimizing the CAR T-Cell Therapy Journey: The Role of Community Oncologists

Announcer:
You’re listening to Project Oncology on ReachMD, and this episode is sponsored by Kite Pharma, a Gilead company. Here’s your host, Dr. Jennifer Caudle.

Dr. Caudle:
Welcome to Project Oncology on ReachMD. I’m your host, Dr. Jennifer Caudle, and joining me to examine the community oncologist’s critical role in advancing CAR T-cell therapy is Dr. Tara Graff. She’s a medical oncologist who leads a community-based clinical trial program at Mission Cancer + Blood in Des Moine, Iowa. Dr. Graff, it’s great to have you on the program.

Dr. Graff:
Thank you for having me.

Dr. Caudle:
Of course. So diving right in, Dr. Graff, CAR T-cell therapy is revolutionizing cancer treatment, but what are some of the challenges community oncologists are facing?

Dr. Graff:
That’s a good question. We know that the treatment paradigm in so many of our disease states is changing, which means newer therapies, and the community oncology role is so important because those patients are in the community. So some of the challenges are first and foremost, knowing when to refer. I feel like not every community oncologist necessarily thinks about CAR T as quickly as they should. The other thing is referral centers; you have to have a good relationship with a nearby treating center, and depending on where you are geographically, that may be a bit of a challenge. And also relationships with those academic or those treating centers is different. And sometimes there’s this hesitance from the physician to refer the patient in fear that they won’t get them back. And also from the patient aspect, patients don’t always want to leave their home to go for a treatment. So it’s not always about medical hangups or performance status, but also the challenges of geography and the logistical situation.

Dr. Caudle:
And could you please explain the referral criteria to treatment centers for continuous care?

Dr. Graff:
Depending on which disease state we’re talking about, where CAR T falls into that treatment line, whether it’s second-line or third-line, is going to be a little bit different. But wherever that is, referring early. I think it’s very, very important to start having those conversations early with patients and early with the treatment center. Just because you have the conversation and start the conversation doesn’t mean the patient is going to get CAR T-cell therapy tomorrow. It’s just the learning process, so you always want to plan ahead. You don’t want to be acting in the 11^th hour. So I really think that the sooner you can start those conversations and the sooner you can at least connect them with a treating center, just to start the momentum I think is key in all of this.

Dr. Caudle:
Those are good points. Now, Dr. Graff, why is collaborating with these treatment centers so important for the journey of oncology patients through CAR T-cell therapy?

Dr. Graff:
I love that question because it’s a team approach, right? This is not a bubble of the community doctor and the academic doctor. I think we make it that way, and I think that’s sort of where this gap gets wider between community and academic centers. It shouldn’t be that way, right? It’s about the patient and the team. We use a multidisciplinary approach in so many cancers from a surgeon to a radiation oncologist to a medical oncologist, so I don’t know why we’re so against having two medical oncologists. I always say you need to have your ‘phone a friend.’ You need to have your academic or your CAR T colleague that you can have a relationship with, and I think if the patient sees that relationship early on—even if they’re not going to go for CAR T or maybe they use it later—it’s like parenting, right? You have the mom and the dad, and they’re the unit. So there’s no reason why you can’t have your home-based oncologist and your academic oncologist, and I think that sets up a sense of peace and reassurance for the patient that their team is working together.

Also, I think it helps to break down some of those barriers that exist in that relationship between the community doc and the academic doc. Community docs are always afraid that if they refer their patient for a CAR T, they won’t get them back, and I think if you have that relationship set up early, it’s a back and forth flow, you know, it’s a “Hey, this is happening here, what do you think I should do?” And you have this relationship versus having these people in certain buckets. So I just think that the sooner you can have that relationship, the better it is for the patient and the better it is for continuous care and communication with the two physicians.

Dr. Caudle:
And I love that. I really do. For those of you who are just tuning in, this is Project Oncology on ReachMD. I’m your host, Dr. Jennifer Caudle, and I’m speaking with Dr. Tara Graff about the pivotal role of community oncologists in advancing CAR T-cell therapy.

So speaking of navigating challenges and opportunities for care, Dr. Graff, how can community oncologists better educate and support patients and their families through the CAR T-cell therapy journey?

Dr. Graff:
So I think it’s about shared decision-making. When I have a patient who is a potential candidate for CAR T, I start that conversation. I have a conversation with them about what that may look like. I also will have a conversation about other treatment options that may exist and clinical trials, but I always say I’m old school. I take the paper on the bed into the exam room, and I pull it out and I get my pen out and I make columns for them. Pros and cons, what this looks, the positives and the negatives, like yes, you might have to travel but it might be a one and done therapy. And then you’re free. You’re not coming in every 2 weeks, every 3 weeks, or whatever the treatment is you’re choosing that wouldn’t be CAR T. But I have a discussion with them. I talk about the social aspect that, yes you won’t be able to sleep in your own bed tonight and it might not be for 15 to 30 days, but you will come back, and I think that reassurance early on that you will come back, I am your home base. I will be involved in everything along the continuum of care. We’ll be in contact with the CAR T center, and I always tell them there’s no harm in hearing a doctor out. Just because I might set up referral for you for a consultation doesn’t mean you have to do it. I mean in a lot of cases, it doesn’t even mean you have to travel. You can do it via telehealth in some cases. But I think starting that conversation early and really understanding and having that relationship with your patient just from a supportive angle, not even a medical or treatment angle, I think is key because education is power for the families and for the patient. I think just kind of explaining to them that we have novel therapies and they’re changing the treatment landscape, and we want to be able to offer that to you or at least have you hear about what’s in store or what could be a possibility in near treatment care.

Dr. Caudle:
And with that in mind, how can community oncologists take a proactive stance in identifying eligible patients for CAR T-cell therapy?

Dr. Graff:
Yeah, this is such an important question and an important topic. It starts with us because the patients are in the community. That’s where they’re at so we are the frontline. It's really imperative that we recognize when these patients should start having a CAR T discussion. It could start as early as when they go into remission with their frontline of therapy. People will ask, “Doc, if I relapse, what’s next for me?” And you can say, “Hey, here’s the novel therapies. Here’s what’s happening. There’s this treatment called CAR T-cell therapy. It uses your own immune system to fight your cancer, and should you be a candidate and need that, that’s a discussion that we should certainly have.” And so you can plant that seed early on, and that way they’re not going to be caught off guard if you actually have to have that conversation.

Dr. Caudle:
Understood. And as our program comes to a close today, Dr. Graff, what impact could a timely referral of this therapy have on a patient’s quality of life and outcome?

Dr. Graff:
So the sooner you refer for CAR T, the better. Lots of times, it’s not even the referral, right, it’s the manufacturing. So there’s so many steps. It’s cell collection, it’s manufacturing, and it’s insurance approval. We know the impact in insurance approval. So you might decide it’s time to go to CAR T, but it could be 60 days before you’re even getting collected or you’re even getting a product. Now we know that some of our companies are doing really well with turnaround time, but you got to get to that point.And there’s a lot of logistics in getting in for a consultation, seeing if you’re a candidate, and prescreening. There’s a lot of steps, so the sooner you do it, the better. Even if it’s "too early," it’s not ''too early"because there’s so many steps along the way. So I would say act early, and that really tends to alleviate some of those logistical things that we as providers cannot control.

Dr. Caudle:
Right. That’s excellent. These are really great insights for us to think on as we come to the end of today’s program. And I’d like to thank my guest, Dr. Tara Graff, for joining me to explore the unique challenges and opportunities of community oncologists in the rapidly evolving landscape of CAR T-cell therapy. Dr. Graff, it was excellent having you on the program today.

Dr. Graff:
Thank you. This was fun. I appreciate it.