'Remarkable' Results With CAR T Cells Could Make Chemo Obsolete

Neil Osterweil

December 11, 2021

ATLANTA — Chimeric antigen receptor (CAR) T-cell therapy has the potential to replace chemoimmunotherapy for second-line treatment of patients with large B-cell lymphoma (LBCL) that have relapsed or are refractory to first-line therapy, results of the phase 3 ZUMA-7 and TRANSFORM trials suggest.

Dr Frederick Locke

In the ZUMA-7 trial, at a median follow-up of 24.9 months, patients randomly assigned to receive CAR T-cell therapy with axicabtagene ciloleucel, or axi-cell (Yescarta) had a median event-free survival (EFS) of 8.3 months, compared with 2 months for patients randomly assigned to standard-of-care chemoimmunotherapy, reported Frederick L. Locke, MD, from the Moffitt Cancer Center in Tampa, Florida.

In TRANSFORM, comparing the CAR T construct lisocabtagene maraleucel, or liso-cel (Breyanzi) with standard-of-care second-line chemotherapy, median EFS was 10.1 months with liso-cel, compared with 2.3 months with standard of care, reported Manali Kamdar, MD, from the University of Colorado Cancer Center in Aurora.

The trials differed slightly in eligibility criteria and other details, but their overall results show great promise for improving second-line therapy for patients with relapsed or refractory large B cell lymphomas (LBCL), commented Laurie Sehn, MD, MPH, from the BC Cancer Centre for Lymphoid Cancer in Vancouver, Canada.

"It's really remarkable that the results are so far in favor of the CAR T-cell therapy that I think it's inevitable that this will become the standard of care," Sehn commented. She was not an investigator on either of the two trials.

I think it's inevitable that this will become the standard of care. Dr Laurie Sehn, BC Cancer Centre for Lymphoid Cancer

Sehn was speaking at a press briefing here at the 2021 American Society of Hematology (ASH) annual meeting. The new data from the two studies were presented at oral sessions, and the results from ZUMA-7 were also simultaneously published in the New England Journal of Medicine.

"For somebody who treats patients with large B-cell lymphoma like I do, it's incredibly frustrating when patients fail frontline therapy," Sehn said. "We come into the second line with more chemotherapy and at higher doses to try and slam things down hard. Particularly for the patients who were enrolled in these studies, which were the worst of the worst — the patients who are either refractory to chemotherapy or relapsed relatively early, within 1 year — it's not surprising that coming in with a novel approach and a cellular therapy that has a proven curative capacity may have outperformed coming in with more chemotherapy."

In an interview with Medscape Medical News, Locke said that, based on the findings of ZUMA-7 trial that he presented, it's likely that chemotherapy in the second-line setting for relapsed/refractory LBCL will largely fall by the wayside.

The first question is to identify the patients who can tolerate CAR T-cell therapy. "We need to refer these patients to a CAR T-cell center to make that decision. That decision really can't be made in the local oncologist's office," he said. "That being said, there are patients who need urgent therapy, and they may need to get second-line chemotherapy right away."

"What we know with CAR T cells is that older patients and patients with comorbidities can get these therapies safely, so to me there is no obvious patient who can't get CAR T-cell therapy," he added.

Also at the briefing, Kamdar, who presented the TRANSFORM trial results, remarked that "in my opinion, this is a breakthrough therapy, which has shown superiority over standard of care, in terms of not just efficacy but also an extremely favorable safety profile," she said at a briefing.   

For patients with LBCL for whom first-line therapy has failed, chemoimmunotherapy followed by high-dose chemotherapy and autologous stem cell transplant (ASCT) has been the standard of care, but only about 25% of patients who are candidates for ASCT achieve durable remissions, Kamdar noted.

Both ZUMA-7 and TRANSFORM were designed to test whether moving CAR T-cell therapy forward into the second line could improve outcomes.

ZUMA-7 Results

THE ZUMA-7 trial randomly assigned 180 patients to receive CAR T-cell therapy with axi-cell and 179 patients to standard of care. This consisted of 2 or 3 cycles of investigator-selected, protocol-defined chemoimmunotherapy, with patients who had a complete or partial response going onto ASCT.

As noted, the primary endpoint of EFS according to blinded central review favored axi-cel, with 24-month event-free survival rates of 41% vs 16% for standard of care. The difference translated into a hazard ratio (HR) for progression or death of 0.40 (P < .001).

In all, 65% of patients had a complete response (CR) to axi-cel, compared with 32% with standard of care. The respective overall response rates were 83% and 50% (P < .001).

Locke pointed out that 94% of the patients assigned to axi-cel received definitive therapy, compared with the 36% of patients in the standard-of-care arm who went on to ASCT.

In an interim analysis, 2-year estimated overall survival was 61% with axi-cel vs 52% with standard of care, although this difference was not statistically significant.

Median overall survival was not reached with axi-cel, compared with 35.1 months with standard-of-care.

Grade 3 or higher adverse events occurred in 91% of patients with CAR T, and 83% with the standard of care. In the axi-cel arm, 6% of patients had grade 3 or higher cytokine release syndrome (CRS), and 21% had grade 3 or higher neurologic events, although there were no deaths related to CRS or neurologic events.


The TRANSFORM trial had broader eligibility criteria than ZUMA-7, including patients who had diffuse LBCL not otherwise specified (de novo or transformed from indolent NHL), high-grade BCL (double- or triple-hit) with DLBCL histology, follicular lymphoma grade 3B, primary mediastinal LBCL, or T-cell/histocyte-rich LBCL.

A total of 184 patients were randomly assigned, 92 in each group, to receive either liso-cel or standard-of-care. Patients assigned to liso-cel were allowed to have bridging therapy, and crossover to liso-cel was allowed for patients assigned to standard of care who either did not have a response by week 9 after randomization, had disease progression at any time, or started a new antineoplastic therapy after ASCT.

As noted before, the primary endpoint of EFS significantly favored CAR T-cell therapy, with a hazard ratio of 0.349 (P < .0001).

The EFS rates at 6 months were 63.3% with liso-cel vs 33.4% with standard of care, and the EFS rates at 12 months were 44.5% vs. 23.7%, respectively.

"Overall survival data were still immature at the time of this analysis, but show a trend favoring liso-cel, despite crossover," Kamdar said.

Grade 3 or higher adverse events (AEs) occurred in 92% of patients on liso-cell and 87% of patients on standard of care. There was one treatment-related death in the liso-cel arm, and two in the standard of care arm, both from grade 3 or higher AEs. Neutropenia, anemia, and thrombocytopenia were the most common treatment-emergent AEs in each group.

ZUMA-7 is supported by Kite. Locke disclosed serving as a scientific advisor to Kite and relationships with other companies. TRANSFORM is supported by Celgene (BMS). Kamdar disclosed consultancy fees from BMS and others.

63rd American Society of Hematology Annual Meeting and Exposition.

Abstract 2, presented December 11 and 12, 2021.
Abstract 91, presented December 11, 2021.

N Engl J Med. Published online December 11, 2021. ZUMA-7 trial full text

Neil Osterweil, an award-winning medical journalist, is a long-standing and frequent contributor to Medscape.

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