Refining patient selection for CAR T-cell therapy in aggressive large B-cell lymphoma

Relapsed or refractory non-Hodgkin B-cell lymphoma is an aggressive disease with a dismal prognosis. Chimeric antigen receptor (CAR) T-cell therapy has emerged as a viable treatment option with durable remissions observed in clinical trials. Due to the risk of toxicities such as cytokine release syndrome and neurotoxicity, careful patient selection is critical to optimize outcomes. Narrow selection criteria were used in clinical trials that led to approval, but a wider range of patients has been successfully treated in the commercial setting. Due to lack of validated pretreatment clinical factors, including risk scores or biomarkers to predict efficacy and toxicity, choosing candidates for CAR T-cell therapy currently relies on expert opinion. Because of logistical constraints and often aggressive disease, we favor referring patients early for cellular therapy at the time of first treatment failure. Herein, we discuss criteria for patient selection using a case-based approach informed by reports of real-world outcomes.