Through presentation of a hypothetical case of a child with B-cell acute lymphoblastic leukemia (ALL) undergoing treatment with chimeric antigen receptor T-cell (CAR-T) therapy at an academic hospital for children, the authors of this article, who were from the Seattle Children’s Hospital, Fred Hutchinson Cancer Research Center, and the Dana-Farber Cancer Institute, among other institutions, provided expert opinion on essential roles of the interdisciplinary team in the provision of comprehensive patient-centered psychosocial care for children and adolescents treated with CAR-T therapy. This article was published in Pediatric Blood and Cancer.
Despite the demonstration of promising clinical activity of CD19-directed CAR-T therapy in children and adolescents with refractory, high-risk B-cell ALL, the high likelihood that treatment will be administered at a specialized center away from the primary oncology team, the potential for severe treatment-related toxicity, and uncertainties associated with prognosis, are some of the challenges commonly encountered by this patient group.
Following a description of comprehensive psychosocial care as being comprised of 4 domains — knowledge/expectations about treatment, mutual understanding of the goals of care, assessment of past and present psychosocial needs, and communication with the referring team — and a description of the stakeholders of the interdisciplinary team — the patient and their family, the primary oncology team, psychosocial service providers, and allied health professionals, among others — the authors focused on providing guidance regarding best practices in 3 areas: psychosocial evaluation and support, communication, and symptom management.
Although a detailed list of recommendations for evaluating the psychosocial needs of children or adolescents for whom CAR-T therapy is planned is beyond the scope of this summary, the authors emphasized the importance of upfront and repeated assessments along the treatment trajectory including evaluations of social determinants of health.
“Understanding the family’s experience with times of crisis, attitudes toward the intensive care unit (ICU), or previous need for support from other consulting services (ie, pain team, nutrition, physical therapy) will help determine current and future social support needs,” the authors noted.
Also recommended was the early involvement of palliative care professionals as part of the psychosocial services component of the interdisciplinary team.
Some of the best practices recommended for achieving effective communication and fostering shared decision-making were explained in the context of the “3Es”: early engagement of the patient, family members, and the primary oncology team; exploration of informational preferences, prior experiences, goals, and concerns; and editing conducted by revisiting previously discussed areas and scheduling future conversations.
Regarding symptom management, the authors stressed that “until the symptom experience of CAR-T cells is better understood, we must heavily rely on partnership with the patient and the family as part of the care team,” especially since early manifestations of cytokine-release syndrome and neurotoxicity can be subtle.
In their concluding remarks, the authors stated that “early and ongoing psychosocial and symptom assessment and partnership with both the family and primary oncology team are paramount to providing high-quality care and successful outcomes.”
They further noted that “as the field continues to make progress in developing innovative approaches to treatment of childhood cancers, approaches to comprehensive care must keep step to ensure that cures and patient-centeredness go hand in hand.”
Steineck A, Wiener L, Mack JW, Shah NN, Summers C, Rosenberg AR. Psychosocial care for children receiving chimeric antigen receptor (CAR) T-cell therapy [published online March 11, 2020]. Pediatr Blood Cancer. doi: 10.1002/pbc.28249