Healthcare Utilization and End-of-Life Outcomes in Patients Receiving CAR T-Cell Therapy

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  • 1 Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital Cancer Center & Harvard Medical School;
  • | 2 Department of Medical Oncology, Center for Lymphoma, Dana-Farber Cancer Institute & Harvard Medical School; and
  • | 3 Department of Psychiatry, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts.
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Background: CAR T-cell therapy has revolutionized the treatment of patients with hematologic malignancies, but it can result in prolonged hospitalizations and serious toxicities. However, data on the impact of CAR T-cell therapy on healthcare utilization and end-of-life (EoL) outcomes are lacking. Methods: We conducted a retrospective analysis of 236 patients who received CAR T-cell therapy at 2 tertiary care centers from February 2016 through December 2019. We abstracted healthcare utilization and EoL outcomes from the electronic health record, including hospitalizations, receipt of ICU care, hospitalization and receipt of systemic therapy in the last 30 days of life, palliative care, and hospice referrals. Results: Most patients (81.4%; n=192) received axicabtagene ciloleucel. Overall, 28.1% of patients experienced a hospital readmission and 15.5% required admission to the ICU within 3 months of CAR T-cell therapy. Among the deceased cohort, 58.3% (49/84) were hospitalized and 32.5% (26/80) received systemic therapy in the last 30 days of life. Rates of palliative care and hospice referrals were 47.6% and 30.9%, respectively. In multivariable logistic regression, receipt of bridging therapy (odds ratio [OR], 3.15; P=.041), index CAR-T hospitalization length of stay >14 days (OR, 4.76; P=.009), hospital admission within 3 months of CAR T-cell infusion (OR, 4.29; P=.013), and indolent lymphoma transformed to diffuse large B-cell lymphoma (OR, 9.83; P=.012) were associated with likelihood of hospitalization in the last 30 days of life. Conclusions: A substantial minority of patients receiving CAR T-cell therapy experienced hospital readmission or ICU utilization in the first 3 months after CAR T-cell therapy, and most deceased recipients of CAR T-cell therapy received intensive EoL care. These findings underscore the need for interventions to optimize healthcare delivery and EoL care for this population.

Submitted September 8, 2020; final revision received October 9, 2020; accepted for publication October 26, 2020. Published online March 11, 2021.

Author contributions: Study concept and design: All authors. Data acquisition: All authors. Data analysis and interpretation: All authors. Manuscript preparation: All authors. Critical revision: All authors. Final approval of manuscript: All authors.

Disclosures: Dr. Jacobson has reported receiving grant/research support from Kite Pharma/Gilead, and serving on an advisory board for Kite Pharma/Gilead, Novartis, Bristol-Myers Squibb/Celgene, Nkarta, Precision Biosciences, and Lonza. Dr. Frigault has reported serving as a consultant for and receiving grant/research support from Novartis and Kite Pharma. The remaining authors have reported that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Funding: This work was supported by funding from the Leukemia and Lymphoma Society.

Correspondence: P. Connor Johnson, MD, Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital Cancer Center, 55 Fruit Street, Yawkey 7B, Boston, MA 02114. Email: pcjohnson@mgh.harvard.edu
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