Dr. Jose Sandoval-Sus, an oncologist at the Moffitt Cancer Center, was recently interviewed with Medscape regarding his review which was published in the October 2022 Current Oncology Reports. The new review is a guide to the treatment of mantle cell lymphoma (MCL) and the impact chimeric antigen receptor (CAR)-T cell therapy has on the disease.
Dr. Sandoval-Sus’s review is somewhat optimistic as he reports that survival rates have increased due to options that help patients live an extra eight to ten years. The survival options are applicable to refractory and relapsed patients as well. However, MCL has yet to be cured.
About MCL
MCL, a rare genetic disease, is one of a group of non-Hodgkin’s lymphomas. MCL are cancers that affect the lymphatic system which is part of a person’s immune system. Also, a type of cancerous B-cells (immune system cells) exists in a lymph node region called the “mantle zone.”
The disease is often diagnosed at advanced stages although the cancers are slow growing Yet Dr. Sandoval-Sus points out that the prognosis is improving.
About the Review
The aforementioned review was published earlier in the year. It includes a study that found median overall survival had increased from 68.2% to 81.6% from 2010 through 2015.
According to the review, several chemotherapy options exist which are combined with rituximab. Rituximab/bendamustine (R/B) for example has been known to be effective in treating MCL at the first relapse.
Dr. Sandoval-Sus said he considers rituximab to be a maintenance medication either after stem cell transplantation or even if patients have not undergone a transplant. He noted that rituximab has contributed to significant improvements.
But he also said that there is an important first step prior to treatment. It is to thoroughly explore all possible clinical outcomes. For example changes to the TP53 gene affect the patient’s prognosis.
The next category, R/R, refers to refracted meaning the cancer is not responding to treatment. Relapsed means that cancer has come back. The review stated that all FDA-approved BTKi’s treating R/R patients appear to have the same clinical outcomes. Unfortunately, right now there are no trials testing a direct comparison.
According to the review, one option might be stem cell transplants but there is a lack of prospective studies on the subject.
CAR-T cell therapy is included as a possible option and is considered a “game-changer” by Dr. Sandoval-Sus. The FDA has approved brexucabtagene autoleucel (Brexu-cel) in the treatment of MCL. It is a type of CAR-T therapy that extends to R/R patients who do not meet study requirements.
Dr.Sandoval-Sus emphasizes early referrals of MCL patients to institutions that are experienced in cellular therapy. A combination treatment of CAR-T and BTKi is under consideration for patients who have not received either treatment (naïve).
The authors of a second review suggested CAR-T cell therapy combined with BTKi as an option because they believe it will increase the efficacy of the treatment.
The information in a second review was achieved through limited data and suggests that the combination therapy might be a bridge that could take place before a CAR-T cell infusion.
A second opinion at an academic facility or a clinic that specializes in treating these lymphomas is highly recommended. Dr. Sandoval-Sus emphasized the importance of molecular tests. He added that stem cell transplant following remission should be on the table as well as exploring clinical trials.
Although the side effects of starting the patient on any BTKi inhibitor must be considered, Dr. Sandoval-Sus still recommends this route for relapsed patients.
The doctor commented that patients come to the CAR-T cell therapy centers somewhat late. He suggested that these patients should receive an earlier referral in order to determine whether they would qualify for the procedure.
As far as CAR-T cell therapy becoming a first-line treatment Dr. Sandoval-Sus explains that it has not yet been FDA-approved. However, the idea is definitely being explored in clinical trials. When asked what message he would give to patients, he said that although MCL is still not curable, the future is bright.
