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Biol Blood Marrow Transplant. Author manuscript; available in PMC 2019 July 12.
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Published in final edited form as:

Biol Blood Marrow Transplant. 2018 June ; 24(6): 1135–1141. doi:10.1016/j.bbmt.2018.02.018.

Building a CAR Garage: Preparing for the delivery of commercial

CAR T products at Memorial Sloan Kettering Cancer Center.
Karlo Perica1, Kevin J Curran2,4, Renier J Brentjens1,4, and Sergio A Giralt3,4
1.Department of Medicine; Memorial Sloan Kettering Cancer Center, New York, N.Y, U.S.A
2.Pediatric
Bone Marrow Transplant Service, Department of Pediatrics; Memorial Sloan Kettering
Cancer Center, New York, N.Y, U.S.A
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3.Adult
Bone Marrow Transplantation Service, Department of Medicine; Memorial Sloan Kettering
Cancer Center, New York, N.Y, U.S.A; Weill Cornell Medical College, New York, N.Y, U.S.A.
4.Cellular
Therapeutics Center; Department of Medicine; Memorial Sloan Kettering Cancer
Center, New York, N.Y, U.S.A.

Abstract
Two commercial Chimeric Antigen Receptor (CAR) T cell therapies for CD19 expressing B cell
malignancies, Kymriah and Yescarta, have recently been approved by the FDA. The administration
of CAR T cells is a complex endeavor involving cell manufacture, tracking and shipping of
apheresis products, and management of novel and severe toxicities. At Memorial Sloan Kettering
Cancer Center, we have identified eight essential tasks that define the CAR T cell workflow. In
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this review, we discuss practical aspects of CAR T cell program development, including clinical,
administrative, and regulatory challenges for successful implementation.

Keywords
CAR T cells; cellular therapy; Chimeric Antigen Receptor; Cytokine Release Syndrome; diffuse
large b cell lymphoma; acute lymphoblastic leukemia

The recent FDA approval of Chimeric Antigen Receptor (CAR) T cell therapies is the
culmination of decades of scientific and clinical development1. Modern CARs were built
from advances in tumor-specific cell therapy2,3, the development of ‘T-bodies’ by Zelig
Eshar4,5, advances in genetic manipulation of primary human T cells6,and the design of a
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second generation of CARs with significantly enhanced potency7,8. Next, physician-

scientists led a series of single center trials that demonstrated CAR T cell activity in relapsed
and aggressive forms of non-Hodgkin’s lymphoma (NHL)9-11, adult acute lymphoblastic
leukemia (ALL)12,13, pediatric ALL14,15, and chronic lymphocytic leukemia (CLL)16.

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 Perica et al. Page 2

We are now faced with administrative and logistic challenge of delivering CAR therapy
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outside the scope of clinical trials. Attention in the scientific and lay press has led to
tremendous excitement and high demand, and meeting expectations will be a challenge.
Patients may assume there will be broad access to these products in a similar fashion to other
chemotherapeutic agents; however, CAR T cells will only be limited to certain centers that
are certified by the manufacturers, and only provided to patients who fulfill strict label
requirements. The process of building cell therapy infrastructure, meeting regulatory
requirements, and ultimately treating patients is a significant undertaking. This review
describes our institutional experience with the development of a CAR T cell program at
Memorial Sloan Kettering Cancer Center (MSKCC) in New York City.

CARs in the Clinic

CARs are minimally composed of two domains: 1) an extracellular antibody fragment
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domain that recognizes tumor-associated antigens, fused via linker and transmembrane
domains to 2) an internal activation signaling domain (such as CD3 zeta) that activates T
cells (Figure 1). Although CARs can theoretically be designed to target any extracellular
antigen, the target antigen CD19, displayed on both normal B cells and in malignant B cell
lymphomas and leukemia at high levels31, has achieved the most clinical success. To
enhance signaling and improve efficacy, second generation CARs7,8 additionally include a
co-stimulatory signaling domain derived from CD28 17,18 or 41BB 18,19. While CD28
containing CARs expand robustly and to rapidly eradicate tumor20, second generation
4-1BB containing CARs are initially fewer in number21 but may better withstand T cell
exhaustion induced by tonic CAR signaling22,23. A full assessment of the relative benefits of
each approach is beyond the scope of this review, but as described below, both CD28 and
4-1BB containing CAR T cells will enter the clinic as FDA approved cellular therapies.
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Tisagenlecleucel (Kymirah)
In 2012, Novartis and the University of Pennsylvania entered into a global collaboration and
licensing agreement which culminated in Novartis’ tisagenlecleucel, tradename Kymriah.
The ongoing ELIANA study (NCT02435849) is the first pediatric global CAR T cell therapy
trial24, while the JULIET study (NCT02445248) is evaluating the efficacy and safety of
tisagenlecleucel in adult patients with relapsed/refractory DLBCL25.

Tisagenlecleucel utilizes a murine single chain variable fragment to recognize human CD19,
linked to a CD8a spacer domain (Table 1). Like the University of Pennsylvania construct on
which it is based, it is a second-generation CAR that utilizes a 4-1BB costimulatory domain,
which has important implications for persistence and activity, as discussed previously.
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Interim analysis of the ELIANA trial for relapsed/refractory pediatric ALL published in June
201724 showed that 83% of patients achieved CR/CRi, with 79% survival at 12 months.
CAR T cells and concomitant B-cell aplasia in peripheral blood were observed for more than
one year in some patients. Approximately 8% of patients suffered manufacturing failures,
and 10% were not infused due to death or adverse events.

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Kymriah (Tisagenlecleucel) was recently FDA approved and carries an indication for
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patients up to 25 years of age with B-cell precursor ALL that is refractory or in second or
later relapse. Notably, ELIANA eligibility criteria required CD19 positivity confirmed
within 3 months of enrollment, excluded patients with active CNS disease or Burkitt’s
lymphoma/leukemia, and required a 6-month delay from transplant.

Axicabtagene Ciloleucel (Yescarta)

Kite pharmaceuticals (Santa Monica, CA), which was acquired by Gilead, developed CAR
technology licensed technology from the National Cancer Institute (NCI). Axicabtagene
ciloleucel, brand name Yescarta, is being evaluated in the ZUMA-1 trial (NCT02614066) for
refractory aggressive non-Hodgkin lymphoma26 (Table 1). Like Kymriah, it utilizes a
murine CD19 binding domain, but unlike Kymriah it contains both a CD28 spacer and a
CD28 co-stimulatory signaling domain.
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Response durability in NHL is lower than that seen in ALL26; of 111 eligible patients, ORR
was 82% and CR 59%; at a median of 15.4 months, 47% of patients were still responding
and 40% in CR. Overall survival at 18 months was 52%.

Patients enrolled in the trial were >18 years old and had relapsed/refractory diffuse large B
cell lymphoma (DLBCL), primary mediastinal B cell lymphoma (PMBCL) or transformed
follicular lymphoma (TFL). Results from the NCI suggest that this construct can be effective
in ‘double-hit’ lymphomas27, suggesting CAR T cells have a role in treating aggressive
disease. However, as in ALL, the patient population most likely to benefit from CAR T cell
administration, and the optimal timing of therapy, are not yet known.

Building a CAR T Cell Program

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The process of CAR T cell administration involves lymphocyte collection, genetic

manipulation, and reinfusion. There are complex logistics involved in collecting cells in the
apheresis center, shipping to the manufacturer for production, and coordinating receipt of the
product.

Several organizations provide standards and regulations for this process. The Federal Drug
Administration (FDA) approves and regulates products, manages adverse event reporting,
and oversee a Risk Evaluation and Mitigation (REMS) process in partnership with the
manufacturers. The Foundation for the Accreditation of Cellular Therapy (FACT) provides
standards for handling, processing, and tracking of cell therapy products28-30. The Center for
International Blood and Marrow Transplant Research functions as a data repository and
conduit between centers and the FDA. Finally, manufacturers themselves inspect apheresis
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and storage facilities, authorize individual centers to provide therapeutics, and provide both
the products themselves and mechanisms for product shipping and tracking.

At MSKCC, we identified eight essential tasks that define the CAR T cell workflow and are
required to successfully implement the delivery of commercial CAR T cell products in the
clinic. We developed this workflow by leveraging the experience of both our investigational
CAR T cell team (Cellular Therapeutic Center) and our adult and pediatric hematopoietic

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stem cell transplantation (HSCT) programs. The overall development was guided by a task
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force headed by a project managers and lead physicians. The task force included physician
representative from leukemia, lymphoma, and bone marrow transplantation, nursing
leadership, laboratory medicine, apheresis and transfusion medicine, legal services, financial
services, social work and hospital administration. The eight tasks together with the
personnel necessary to implement them are depicted in Figure 2.

Task 1: Patient Intake

Institutions must build an effective administrative infrastructure to facilitate patient referral,
selection, and evaluation. This includes administrative staff to field calls and intake, nursing
staff for triage and coordination, and financial and insurance advisers to ensure eligibility.
While common to all medical enterprise, intake and pre-screening are particularly important
for CAR T cell, as demand is likely to be high, eligibility is limited, and the availability of
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CAR T cells will at least initially be limited to a small number of centers.

Task 2: CAR T Cell Consultation Service:

We next developed a CAR T cell consultation service to handle patient selection and
treatment. The consultation service consists of physicians, nurses, and social workers with
expertise in CAR T cell therapy. Specialized physicians must be trained and registered with
both the institution and manufacturers as CAR certified MDs who are authorized to
prescribe CAR products and manage CAR patients.

A key task of the consultation service includes assessing patients for therapy. Appropriate
candidates must have disease that will benefit from CAR T cell treatment, fit the labeling
indication for the product, be well enough to receive therapy, have a caregiver, be able to
stay within 2 hours of the treating institution for one month, and have insurance coverage or
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other financing for treatment. Disease burden at time of evaluation is a critical consideration,
as patients with low burden of disease experience fewer treatment related toxicities and
appear to derive more benefit from treatment13.

If investigational cell therapy products are available, patients must be triaged between the
commercially available products and clinical trials. In some cases, this will be
straightforward and based on product labeling; for example, a 27-year-old with ALL is not
eligible for Kymriah, and an adult with Mantle Cell Lymphoma is not eligible for Yescarta.
At other times, patients will be eligible for commercial CAR products, standard of care
treatment, and clinical trials. Therefore, it is important to create a process by which patients
and physicians can decide on the appropriate therapy.
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Of particular importance is that patients continue to receive therapy that is most appropriate
for their disease; thus, for example, patients with chemosensitive relapsed DLBCL should be
treated with an autologous HSCT after high dose BEAM until the appropriate randomized
trials of CAR T vs autologous HSCT have been performed. At our institution, candidates are
reviewed at a weekly conference which brings together CAR certified MDs and disease-
focused specialists.

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Task 3: CAR T Cell Collection, Ordering, Shipping and Receiving

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CAR T cell therapy requires an apheresis center and cell storage facility where T cells can
be harvested, maintained, and easily transferred. This requires training of apheresis
personnel, cell therapy technologists, administrative personnel, and nursing coordinators to
process CAR products. Such centers and the products they generate are regulated by and
must be registered with the FDA.

Despite concerns regarding leukopenia in these heavily pre-treated patients, minimal

required collections can be successful in more than 90% of patients, with optimal yields in
approximately 70% 31. There are, however, minimal requirements for initiation of collection;
the Novartis product, for example, requires absolute lymphocyte counts > 500 mcL/L or
absolute CD3+ T cell counts > 150 mcL/L.

Both Novartis and Kite have an extensive contracting process to establish technical and
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quality agreements for apheresis and cell processing facilities. The goal of these agreements
is to ensure a high-quality cell product is delivered reliably to the manufacturer.
Manufacturers work with the institution to define processes for tracking and verifying
product identity, manipulating and storing products, and training personnel. Importantly, cell
manipulation and freezing protocols must be reconciled with technical standards established
by each company without significantly disrupting existing practice. This is a thorough and
time-consuming process which involves on-site inspections by the manufacturer and, in
certain cases, mock shipments.

Kymriah, but not Yescarta, can be collected, frozen, and stored for later use, a strategy
Novartis has termed “at risk collection.” The acceptable duration of storage is validated up
to 9 months per the manufacturer. Similarly, the optimal timing for collection is not known,
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although theoretically early collection before patients are heavily pre-treated and leukopenic
may be beneficial.

Once collected, apheresis products are shipped to a commercial facility where T cells are
isolated, activated, genetically modified with a CAR-encoding vector, and expanded prior to
cryopreservation. Our own institutional process of clinical CAR- T manufacturing is
reviewed in Wang et al32. After processing, they are shipped back to the originating
institution. One critical area of focus, and a key focus of FACT standards, is ensuring chain
of custody of the cell product. Staff must be trained on the software programs developed by
each product manufacturer which coordinates shipping and ensures product identity.

Task 4: Bridging Strategy

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Average turn-around time for initial apheresis to return of cells to the clinical site is 17 days
for Yescarta33, with some products requiring 2-4 weeks before minimum cell numbers are
obtained; slow expansion, insurance authorization and treatment planning can extend the
bridging period to 1-2 months. While time-to-infusion has been drastically reduced, many
patients have aggressive malignancies which must be carefully managed during insurance
authorization, apheresis and manufacture. In selecting patients for CAR T cell therapy,
clinicians must evaluate the pace of disease progression, the potential for near-term
complications, and the expected date of infusion.

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This process is managed in collaboration between the disease-specific primary oncologist

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and the CAR T cell consultation service, with nursing and administrative staff in support.
Alternative therapies for patients who suffer manufacturing failures or disease complications
should be considered; for example, in ZUMA-1, 101 of 111 patients ultimately received
therapy26, with one manufacturing failure, one rapid disease progression, and several
interval adverse events and other medical complications.

Two to seven days prior to infusion, patients receive a lymphodepleting conditioning

regimen to enhance CAR T cell function and engraftment34,35. This requires the
development of order sets specific to the conditioning regimen used for each commercial
product.

While there are slight differences in the conditioning regimens use for different products and
trials, investigators have coalesced around low-dose cyclophosphamide and fludarabine, as
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utilized in JULIET and ZUMA-1. The optimal conditioning regimen has not been rigorously
defined, but experiences at the NCI10 and Fred Hutchinson Cancer Center36 are illustrative,
with more aggressively lymphodepleting regimens associated with both increased expansion
and toxicity.

Task 5: CAR T-Cell Infusion

Infusion requires the development of order sets, nursing standard of practice protocols, and
documentation and verification procedures for administration. As part of FACT
accreditation, electronic cell therapy orders must be developed for collection and thaw/
infusion products and must be recorded in chemotherapy administration records. Therefore,
pharmacy may track and register cell products and a work-flow for pharmacy involvement in
product administration should be developed.
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Consents must be developed for cell collection and infusion. Although specific consents are
not mandated by regulatory agencies, the complex process and significant toxicity suggests a
thorough patient consent process should be a central part of CAR T cell administration.

Task 6, Post Infusion Care (Day 0 to 30):

After infusion, patients are at risk for CAR T cell related adverse effects. The Cytokine
Release Syndrome (CRS)12,37,38 occurs on a spectrum from low grade fever, which may not
require any treatment, to fulminant multi-organ failure, which requires intensive care and
aggressive immunosuppression. In some studies, approximately 10-15% of CAR T cell
patients have required vasopressor support for hypotension and/or mechanical
ventilation36,39. The mainstays of treatment for severe CRS include the anti-IL6R antibody
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Tocilizumab, high-dose steroids, and supportive care delivered in an intensive care unit40.

In addition to CRS, a syndrome of neurologic toxicity has been described41,42. Severe

neurologic toxicities include encephalopathy, nerve palsies, and seizures, and have resulted
in patient deaths43,44; these are often preceded by more subtle deficits in complex
commands such as hand-writing, word-finding, and attention40. Information on the
appropriate clinical management of CRS and other CAR T toxicities is both extensively
reviewed elsewhere40,45 and is available on the package insert of approved therapies.

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Subspecialists in Neurology and Intensive Care must be educated about CAR specific
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toxicities. We have developed management guidelines to harmonize treatment of CRS and

neurotoxicity across departments and between commercial products and clinical trials.
However, different products and disease indications have different rates and patterns of
toxicity, and clinical judgement must be used in applying guidelines. Tisagenlecleucel
induced severe CRS (Grade 3 or 4 by the UPenn toxicity criteria) in 48% of pediatric and
young adult ALL patients in ELIANA24 and 28% of adult DLBCL patients in JULIET25,
while ZUMA-1 reported a 13% rate (by NCI Common Terminology Criteria for Adverse
Events) for axicabtagene ciloleucel in adult DLBCL.

CRS correlates with disease burden in pediatric trials46. Similarly, in adult ALL trials, severe
CRS has only been observed in patients with morphologic evidence of disease at time of T
cell infusion (> 5% bone marrow blasts) 13,47. Therefore, patients with a low burden of
disease but a high risk of relapse may be optimal candidates for CAR therapy.
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Nurses and ancillary medical personnel must also be educated about the recognition of CAR
T cell specific care and toxicities, including CRS and neurotoxicity. Nursing units with
experience in managing leukemia, lymphoma, and transplant patients are also well suited to
handling more common issues including infection48 and transfusion. All physicians, mid-
level providers, pharmacists and nurses who will interact with CAR T cell patients must
undergo FDA mandated training as part of a Risk Evaluation Mitigation Strategy (REMS).
This includes training which is provided by manufacturers on CAR-specific toxicity
management with a knowledge assessment and the ability to audit these assessments if
requested by the FDA as part of an adverse event assessment.

By FDA mandate, the inpatient pharmacy will need to stock at least two doses of
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Tocilizumab for each patient prior to CAR T cell administration, and ordering protocols and
order sets will need to be developed to assure timely administration of both anti-IL6 therapy
as well as corticosteroids and supportive medications as needed for CRS.

Each institution must undertake a thoughtful assessment of anticipated patient volumes,

which depend on referral rates, relapse and treatment patterns, average length of stay, and
relapse and complication rates. Although neither of the two products currently approved
require an up-front hospitalization, both carry a significant risk of neutropenic fever, CRS,
and neurotoxicity, resulting in an average a length-of-stay of 10-14 days. The need for
inpatient admission, intensive care, and subspecialty care (such as neurology consultation)
needs to be anticipated and requires planning by multiple departments.

Outpatient administration and management of patients undergoing CAR T cell therapy is

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feasible but requires well-staffed, dedicated outpatient units like those used to monitor
outpatient autologous HCT recipients. Older patients, patients with bulky disease and
patients with more comorbidities are likely to be at higher risk for complications and thus
closer monitoring will be reasonable. Since a large proportion of patients will be coming
from a significant distance, provisions must be made for lodging, transportation and living
expenses. Patients and caregivers must be educated on CAR T toxicities and are given a

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manufacturer-provided wallet card describing symptoms that warrant immediate evaluation,

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such as fevers which can herald the onset of CRS or infection.

Task 7, Post-Infusion Care (Day 30 Onwards):

Documentation and hand-off procedures must be established to transition successfully
treated patients to the outpatient setting. Order sets, standards of practice, and
documentation must be developed for this purpose. The role of CAR T cell consultation and
disease-specific groups must be delineated in patient monitoring and follow up. As
discussed below, patients must be assessed for disease response at one month.

The use of CAR T cells in R/R B-ALL raises the question if subsequent allogeneic stem cell
transplant is needed for durable remission. The University of Pennsylvania experience with
adult and pediatric ALL showed long-term persistence of CAR cells, and only 9% patients
went on to receive all-HSCT15. Similarly, the recently published MSKCC experience did not
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demonstrate a survival difference among patients with MRD negative complete response
after CAR therapy who underwent transplant compared to those who did not13. Prospective
randomized control trials comparing a “bridge-to-transplant” compared to CAR-only
approach are not available but will be quite informative as this question is key to the
successful use of this technology.

When patients do relapse, it is often due to CD19 undetectable disease with detectable CAR
T cells in the peripheral blood46. Lymphoid cells can also express CD19 isoforms that do not
contain CAR binding domains49. In either case, re-treatment with CD19 CAR would not
have clinical activity; however, alternative targets such as CD2050 and CD2251,52 are in
development.
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Task 8, Financing, Regulatory and Reporting Requirements:

Administrative personnel will need to be educated on the billing and reimbursement
protocols for CAR therapy. Novartis has announced a unique payment paradigm for
Kymriah, which carries a nearly half-million price tag contingent upon response at one
month53. CRs are thankfully quite high, however, suggesting hospitals will face the full costs
for at least 4/5th of patients. Yescarta is priced at $375,000 per patient. Notably, these costs
account only for the therapy itself, and do not account for hospitalization and numerous
ancillary processes required for CAR T cell therapy (“parts, not labor”). Extrapolating from
experience with bone marrow transplantation, management of patient hospitalization and
complications is likely to contribute at least another $200,000-$500,000 depending on
complication rates 54, which brings the total price tag close to one million dollars. Private
payors will likely announce strict, label-specific requirements, while public payors will need
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to create new Diagnosis Related Groups and other funding mechanisms to accommodate
cost. Regardless, institutions must be prepared to face significant downside financial risk.

From a regulatory perspective, gene therapy that is deemed “high risk,” including the use of
integrating vectors, carries an FDA requirement to track patients for up to 15 years after
administration. This requirement stems from potential oncogenic transformation that has
been seen in several patients infused with genetically modified hematopoietic stem cells

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used for the treatment of primary immune deficiency55. However, oncogenic transformation
in mature T cells has not been observed56,57.
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Data management personnel are needed for obligatory data reporting on outcomes,
particularly severe adverse events. FACT recommends that elements of CIBMTR cellular
therapy data forms, including patient demographics and outcomes, are captured at regular
follow-up intervals. Manufacturers have established reporting requirements for CAR-related
toxicities: all incidents of CRS and neurotoxicity must be reported, and manufacturers also
encourage reporting of severe and unusual toxicities. Events may be reported directly to the
FDA via MedWatch or to the manufacturers.

Conclusion
Built on decades of scientific advancement and clinical development, CAR T cells are a new
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treatment paradigm for previously intractable malignancies. While CAR T cells were
initially developed in a few academic centers, they have been approved at a time where no
center has treated more than 400 patients. Each institution that initiates a CAR therapy
program will face both clinical and administrative challenges, and the next decade will no
doubt bring significant knowledge of the optimal use and management of these powerful
tools. Despite significant financial, regulatory, and administrative barriers, we must not lose
sight of the tremendous benefit that CAR T cells, skillfully deployed and thoughtfully
applied, can bring to our patients.

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Highlights:
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• Commercial Chimeric Antigen Receptor T cell products are efficacious, but

the delivery of cell products requires significant planning and coordination

• A consultation service composed CAR-certified physicians identifies and

manages patients

• Apheresis requires significant coordination with manufacturers, including site

inspection and sample tracking

• Toxicity management requires REMs training for all providers, and

participation of ICU and neurology specialists

• Regulatory standards are provided by the FDA, CIBMTR, FACT and product
manufacturers
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Figure 1: Antigen Recognition by T cells

T cell receptors recognize intracellular antigens presented as peptides in the context of major
histocompatibility complex (MHC). First generation (1G) CAR T cells target extracellular
tumor-associated antigens using an antibody-derived Single Chain Variable Fragment (scFV;
blue) fused to an adaptor domain (tan) and internal CD3ζ signaling domain (purple). Second
Generation (2G) CAR T cells incorporate a co-stimulatory domain (red) for enhanced T cell
function. Co-stimulation is commonly provided through signaling of CD28 or 4-1BB.
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Figure 2:
The eight essential steps required to establish a CAR T cell program and the personnel
required to implement them. Key regulatory agencies involved in each step are denoted by a
bullet.
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Table 1:

Characteristics of Approved CAR T Cell Products

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Company Gilead (KITE) Novartis

Product Name Axicabtagene Ciloleucel Tisagenlecleucel

Academic License NCI University of Pennsylvania

Binding Domain FMC63 FMC63

(All Murine ScFv)

Indications DLBCL, TFL PMBCL Pediatric ALL

<26 yrs old

Spacer Domain CD28 CD8α

Transmembrane Domain CD28 CD8α

Stimulatory Domain CD28-CD3ζ 4-1BB-CD3ζ

Starting Cell Population Selection None None

Final CD4/CD8 ratio Variable Variable

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Ablation Technology None None

Viral Vector Gamma retrovirus Lentivirus

Outcomes
CR Rate NHL 54% ALL 83%
Grade 3-5 Cytokine Release 30% 30%
Grade 3-5 Neurotoxicity 30% 30%
Average LOS on Study 14 days NS

Projected Demand in the United States 4000 to 6000 patients 400-600 patients
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