R/R LBCL: A Practical Guide to CAR T Referral and Coordination

Announcer:
You’re listening to Project Oncology on ReachMD.

This program, titled “R/R LBCL: A Practical Guide to CAR T Referral and Coordination,” is sponsored by Bristol Myers Squibb.

Here are your hosts, Dr. Loretta Nastoupil and Dr. Manali Kamdar.

Dr. Nastoupil and Dr. Kamdar were compensated by Bristol Myers Squibb for their participation.

Dr. Nastoupil:
You’re listening to Project Oncology on ReachMD. I'm Dr. Loretta Nastoupil, oncologist with Southwest Oncology and CommonSpirit Mercy in Durango, Colorado.

I'm joined today by Dr. Manali Kamdar, Professor of Medicine and Clinical Director of the Lymphoma Program at the University of Colorado School of Medicine and the UCHealth Blood Disorders and Cell Therapies Center in Aurora, Colorado.

We'll be talking about chimeric antigen receptor T-cell, or CAR T, therapy in relapsed and refractory large B-cell lymphoma, or LBCL—how to identify the right patients, when to refer, and how the shared-care process works in practice. Dr. Kamdar, welcome to the program.

Dr. Kamdar:
Thanks, Dr. Nastoupil. I’m happy to join you for this conversation today.

Dr. Nastoupil:
Let's start by framing the treatment landscape, Dr. Kamdar. The way we approach second-line LBCL has changed substantially—and CAR T has been central to that shift.^1,2 Treating clinicians refer potential candidates to a CAR T treatment center, where CAR T specialists will evaluate the patient’s eligibility.^3,4 For clinicians who may not work with it daily, can you walk us through the mechanism and where it sits in the treatment paradigm?

Dr. Kamdar:
Absolutely. CAR T cell therapy uses a patient’s own genetically modified T-cells to target CD19-expressing lymphoma cells and trigger cytotoxic tumor cell killing.⁵

Relapsed or refractory LBCL has historically been associated with poor outcomes after first-line failure.^1,2 Randomized phase 3 trials demonstrated improved outcomes with CAR T cell therapy compared with the historical standard—salvage chemoimmunotherapy followed by autologous stem cell transplant. Those findings helped establish CAR T cell therapy as a standard-of-care option in the second-line setting for appropriate patients.²

NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines^®) designates CAR T as an NCCN Category 1 recommendation for second-line patients with primary refractory disease or relapse within 12 months of first-line therapy, and also includes CAR T as a preferred regimen for patients who relapse after 12 months and aren’t heading to transplant. So we should be thinking about CAR T cell therapy as an established treatment approach in this setting.²

What do you think, Dr. Nastoupil?

Dr. Nastoupil:
I agree, and that standard-of-care framing has important implications for referral timing.⁶ LBCL is an aggressive disease,⁷ and outcomes data suggest CAR T cell therapy may be more effective earlier in the treatment course, particularly in the second-line setting.^7,8

Dr. Kamdar:
Well said. One of the areas where real-world practice and the evidence sometimes diverge is around eligibility.⁶ There's a tendency to apply transplant eligibility criteria to CAR T candidates. So how do you think about that gap, Dr. Nastoupil?

Dr. Nastoupil:
That's an important misconception I want to address today. Eligibility for CAR T cell therapy is broader than for autologous stem cell transplant.^6,9

First, age alone shouldn’t automatically preclude referral, because clinical trial data and real-world experience has shown that older adults may still be appropriate candidates depending on the overall clinical picture.^6,9

Performance status and organ function also require some flexibility in how we think about eligibility, particularly when disease burden is contributing to symptoms or laboratory abnormalities. Cardiac, renal, pulmonary, and hepatic function remain important, but the criteria for CAR T cell therapy may differ.^6,10 

That’s why early referral and multidisciplinary evaluation with CAR T specialists can be so valuable in helping determine who may be an appropriate candidate.^3,8,11

What are your thoughts, Dr. Kamdar?

Dr. Kamdar:
In my experience, these comorbidities don’t usually disqualify someone. Early involvement of cardiology or pulmonology may help some borderline patients remain candidates.^6,9,12,13 

And the data support that broader view. Clinical trial data from studies that enrolled patients, including older adults and patients with comorbidities, showed meaningful outcomes with CAR T cell therapy.^14,15

Registry analyses have also shown that many patients treated outside of clinical trials wouldn’t have met the eligibility criteria used in some of the earlier pivotal studies, yet outcomes remained generally consistent with what was observed in the clinical trial setting.^9,16,17

Dr. Nastoupil:
For those just tuning in, you’re listening to Project Oncology on ReachMD. I'm Dr. Loretta Nastoupil, and I’m speaking with Dr. Manali Kamdar about CAR T cell therapy in relapsed and refractory large B-cell lymphoma.

Dr. Nastoupil:
So, Dr. Kamdar, let's talk now about how the care coordination model actually works across settings.

Can you walk through how you think about the partnership between the referring provider and the academic center across the CAR T journey?

Dr. Kamdar:
Absolutely. The referring oncologist is central to the CAR T process because they initiate the consultation with CAR T specialists to evaluate patient eligibility. And they often remain involved throughout treatment planning and coordination, which may include bridging therapy.^3,8,12

Then the patient comes to the treatment center for lymphodepleting chemotherapy, infusion, and monitoring for acute adverse events before transitioning back to the referring oncologist for follow-up and long-term management.^8,13

Dr. Nastoupil:
And once the patient transitions back, the referring oncologist still plays an important role in monitoring blood counts, immune recovery, and longer-term follow-up.^3,13 Monitoring requirements have also evolved over time to a minimum two-week period to allow appropriate patients to return home earlier.¹⁸

In my experience, the most successful cases involve active communication between the referring practice and the treatment center throughout the treatment journey.^3,8,13

Dr. Kamdar:
One of the challenges we still face is that, despite the progress we have seen with CAR T cell therapy, relatively few patients ultimately receive it. Some analyses suggest that only about 15 percent of eligible patients with relapsed or refractory LBCL go on to receive CAR T cell therapy.^8,19

Select real-world evidence also shows that roughly 46 percent of eligible patients remain at non-CAR T treatment sites without referral, and that disparity doesn’t appear to be explained solely by clinical ineligibility.¹⁹

So, Dr. Nastoupil, what barriers do you encounter most consistently that can make referral more difficult in practice?

Dr. Nastoupil:
Well, eligibility uncertainty is one, which we've covered.⁶ Logistical barriers can be a contributing factor, too.^8,13 A patient may live two hours from the nearest CAR T treatment center, or they may not have a reliable caregiver. They may be worried about travel, expenses, or time away from work. 

Non-clinical factors—such as who can drive the patient or whether a spouse can take time off—are important context that help shape the support patients may need.^3,8

Dr. Kamdar:
That context is useful for the CAR T treatment center as well. CAR T centers typically have dedicated nurse coordinators, social workers, and financial navigators, so early referral gives us more time to address them, to resolve insurance issues, and for the logistics to come together. Simply put, the earlier we understand the barriers, the more realistic and personalized the care plan can be.^3,6,8,13

Dr. Nastoupil:
Toxicity perception is another barrier that comes up frequently. Cytokine release syndrome, or CRS, and neurologic toxicity are real risks, and they should be discussed clearly with patients as part of the monitoring process.^8,10,18

Emerging clinical experience has shown that 96 percent of these events occur early within the first two weeks after infusion—while patients are still being closely monitored by the treatment center. Many events have been low-grade and have resolved with appropriate monitoring and management.^18,20,21

That’s important for referring oncologists, because these toxicities are typically managed by the CAR T team during that early monitoring period.^8,18

With that being said, Dr. Kamdar, how do you counsel patients on the safety profile?

Dr. Kamdar:
The monitoring protocols reflect how seriously treatment centers take these adverse events. Patients are monitored closely after infusion for signs of CRS and neurologic toxicity, and caregiver education is an important part of that process.^8,18

Communication between the treatment center and the referring team is also critical so everyone understands what to watch for, when to call, and how follow-up will be coordinated once the patient transitions back to their referring provider.^3,13

Dr. Nastoupil:
So, Dr. Kamdar, let's close with what's actionable. If there are two things that should shift in practice, what are they?

Dr. Kamdar:
I’d say refer at first relapse, not after the next failure.⁶ CAR T is NCCN Category 1 in the second-line setting, and the time to initiate the referral is the moment that relapsed or refractory disease is a concern.² Outcomes appear to be better with earlier use, so referral should happen before that window narrows.^6,8

Because we’re still treating with curative intent in the second-line LBCL setting, it’s important to refer early enough to preserve the opportunity for durable remission in eligible patients.^6,8 

What would you add, Dr. Nastoupil?

Dr. Nastoupil:
I’d encourage our colleagues to apply the right eligibility framework, because advanced age, comorbidities, and borderline organ function are not automatic disqualifiers.^6,9

So if you’re unsure, involve the treatment center early. This is a shared-care process, so the referral itself is an opportunity to start the conversation. The bottom line is simply: don't wait to refer. Consult with a CAR T specialist for all on-label patients—because early evaluation gives patients the best opportunity to be considered for appropriate treatment options.^6,8

As those final insights bring us to the end of today's program, I'd like to thank my guest, Dr. Manali Kamdar, for her insights on how we can best collaborate in CAR T referrals for appropriate patients with relapsed and refractory LBCL. Dr. Kamdar, thanks for a great conversation.

Dr. Kamdar:
It’s been a pleasure. Thank you so much, Dr. Nastoupil.

Dr. Nastoupil:
For ReachMD, I’m Dr. Loretta Nastoupil. 

Announcer:
This program was sponsored by Bristol Myers Squibb. If you missed any part of this discussion or to find others in this series, visit Project Oncology on ReachMD.com, where you can Be Part of the Knowledge.

References:

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2. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines^®) for B-Cell Lymphomas V.4.2026. © National Comprehensive Cancer Network, Inc. 2026. All rights reserved. Accessed June, 1, 2026. To view the most recent and complete version of the guideline, go online to NCCN.org. NCCN makes no warranties of any kind whatsoever regarding their content, use or application and disclaims any responsibility for their application or use in any way.
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