CAR-T Cell Therapy: the Efficacy and Toxicity Balance

Abstract

Purpose of review: Chimeric antigen receptor (CAR) T cell therapy is an immunotherapy that has resulted in tremendous progress in the treatment of patients with B cell malignancies. However, the remarkable efficacy of therapy is not without significant safety concerns. Herein, we will review the unique and potentially life-threatening toxicities associated with CAR-T cell therapy and their association with treatment efficacy.

Recent findings: Currently, CAR-T cell therapy is approved for the treatment of B cell relapsed or refractory leukemia and lymphoma, and most recently, multiple myeloma (MM). In these different diseases, it has led to excellent complete and overall response rates depending on the patient population and therapy. Despite promising efficacy, CAR-T cell therapy is associated with significant side effects; the two most notable toxicities are cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). The treatment of CAR-T-induced toxicity is supportive; however, as higher-grade adverse events occur, toxicity-directed therapy with tocilizumab, an IL-6 receptor antibody, and steroids is standard practice. Overall, a careful risk-benefit balance exists between the efficacy and toxicities of therapies. The challenge lies in the underlying pathophysiology of CAR-T-related toxicity which relies upon the activation of CAR-T cells. Some degree of toxicity is expected to achieve an effective response to therapy, and certain aspects of treatment are also associated with toxicity. As progress is made in the investigation and approval of new CARs, novel toxicity-directed therapies and toxicity-limited constructs will be the focus of attention.

Keywords: CAR-T; CAR-T efficacy; CAR-T neurotoxicity; CAR-T toxicity; CRS; ICANS; Immunotherapy.

Fig. 1

Toxicity and efficacy balance in CAR-T cell therapy. Illustration representing immune and CAR-T cell activation leading to tumor death, cytokine release syndrome (CRS), and neurotoxicity with overview of associated pathophysiology. IL, interleukin; MCP-1, monocyte chemoattractant protein-1; MIP-1b, macrophage inflammatory protein-1b. Figure created with BioRender.com