Sarah Nikiforow, MD, PhD
Dana-Farber Cancer Institute | Boston, MA | Technical Director, Immune Effector Cell Program
In 2020, Sarah Nikiforow, MD, PhD, embarked on a journey to standardize safety procedures for commercial chimeric antigen receptor (CAR) T-cell therapies with the goal of improving patient access to these transformative therapies. The work, supported by the American Society for Transplantation and Cellular Therapy, required collaboration across the field, including with makers of the therapies, quality accreditation bodies, medical experts, and the FDA.
Her vision became a reality when the FDA removed product-specific Risk Evaluation and Mitigation Strategy (REMS) requirements for six CAR T-cell therapies and instead deferred to the safety programs already in place at Dana-Farber and most other CAR T-cell centers. A recently approved seventh therapy followed the same approach, requiring no REMS program.
"The change signals that CAR T-cell therapies have matured from novel, unfamiliar medicines to well-understood therapies with familiar safety approaches," says Nikiforow, medical director of Connell and O’Reilly Families Cell Manipulation Core Facility. "These changes do not compromise safety for patients, and they could make receiving CAR T-cell therapy less burdensome for some individuals. They will also enable Dana-Farber and other cancer centers to offer new CAR T-cell therapies much faster once they are approved by the FDA."
The first-approved CAR T-cell therapy included this special FDA REMS safety requirement. The therapy had potentially life-threatening side effects that were unfamiliar to many providers. To mitigate the risks of these side effects, the FDA enacted extra cautionary steps mandating provider training, specific side effect management procedures, patient tracking, reporting, and auditing. In quick succession, five more CAR T-cell therapies were also approved. Each came with its own FDA-mandated REMS, meaning that each approved therapy had a different set of safety procedures.
"At a certain point, the product-specific safety parameters were actually becoming roadblocks to patient access to therapies because there was so much work needed to support each individual product," says Nikiforow. "We saw an opportunity to leverage existing standardized safety approaches, data registries, and accreditation programs."
Nikiforow partnered with Frederick Locke, MD, at Moffitt Cancer Center to bring colleagues together to advocate for application of existing safety standards to the common risks across all approved CAR T-cell therapy products. Through Nikiforow’s leadership, the collaborative working group agreed upon and published recommended management, monitoring, and reporting approaches and resources to ensure safety for these types of shared risks. The remaining list of product-specific safety concerns are managed through safety procedures unique to each product.
As new types of cell therapies enter the clinic, safety programs will be continuously reviewed and updated by experts across the field.