Real World Evaluation of Deviation Outcomes in an Immune Effector Cell Quality Program

Introduction

City of Hope (COH) was one of the first institutions to be granted Immune Effector Cell (IEC) Therapy accreditation by the Foundation for the Accreditation of Cellular Therapy, which supports our mission to provide safe, high quality patient care through expanded standardization. As part of the accreditation requirements, COH expanded established processes developed to monitor standard of care (SOC) deviations for the Hematopoietic Cell Transplantation Program to our IEC Clinical Program. As part of process improvement, we monitored our IEC Quality program to determine if there were any outcome changes as a result of deviations. Therefore, we performed a retrospective analysis of electronically submitted SOC deviations for patients treated with commercially available chimeric antigen receptor (CAR) T cell products (tisagenlecleucel or axicabtagene ciloleucel [Axi-cel]) between December 2017- March 2020 at COH.

Methods

During the reporting timeframe, 122 patients were planned to be treated with an IEC product. We retrieved 28 requests for SOC deviations from our electronic database for 24 of 122 patients. We analyzed for volume, trends and patient outcomes of submitted deviation requests, including trends in type of deviation, transfer to the intensive care unit (ICU), length of inpatient hospital stay and safety outcomes at 30 days post infusion. Patients who did not receive their SOC product for any reason during the reporting timeframe, or were lost to follow-up were excluded from the outcomes analysis.

Results

Sixteen of 24 patients were planned to be treated with SOC Axi-cel and 8 of 24 patients were planned to be treated with tisagenlecleucel; only 19 of 24 patients (10 women and 9 men) underwent infusion with their respective SOC product, 15 with Axi-cel and 4 with tisagenlecleucel. Five of 24 patients, including 1 Axi-cel and 4 tisagenlecleucel patients were excluded due to change in medical condition or infusion after the reporting timeframe. We identified elevated creatinine levels as the most common reason for SOC deviation requests for patients to be treated with tisagenlecleucel (4 of 8 patients), while deviations relating to rest days between lymphodepletion and CAR T cell infusion were the most common submitted deviations for patients planned to be treated with Axi-cel (9 of 16 patients).

We also descriptively compared patients who required SOC deviations to a cohort of patients (n=98) who did not require deviations and were treated with either axicabtagene ciloleucel (n=86) or tisagenlecleucel (n=12) during the same timeframe. Eight of 98 (8%) of patients who did not have requests for SOC deviation were transferred to the ICU compared to 4 of 19 (21%) patients who required SOC deviations. Seventeen of 19 and 94 of 98 patients were discharged. The median length of inpatient hospital stay post infusion for SOC deviations cohorts who were discharged was 16 days (11-40) and 15 days (8-100) for non-SOC deviations patients. When we descriptively compared survival outcomes at 30 days post infusion, we found that all (4 of 4) patients who required SOC deviations and received tisagenlecleucel survived compared to 11 of 12 patients without SOC deviations. For patients who received Axi-cel, 14 of 15 patients with SOC deviations survived at day 30 post infusion compared to 85 of 86 patients without SOC deviations. The response to treatment and toxicities will be reported at the meeting.

Conclusion

These data suggest that careful selection of patients who may benefit from SOC deviations and still receive their infusion may not negatively affect survival outcomes at 30 days. The SOC deviation review process offers physicians a forum to evaluate non-SOC eligible cases and advise on SOC policy changes. While preliminary, our quality review identifies a role for comprehensive analysis of all IEC SOC deviations as part of standard practice, especially as the field of cellular immunotherapy expands to include more SOC cellular products. Overall, further monitoring of SOC deviations in real world patient populations treated with commercially available IEC products will allow us to continue to support patient safety, assess patient care management practices, expand patient access, meet accreditation standards and monitor SOC practice changes while advancing the field of cellular immunotherapy.