What to Expect When Starting CAR T-Cell Therapy for Multiple Myeloma

T cells are collected through a process called leukapheresis. Here’s what to expect during the procedure.

1. Once you arrive at the treatment center, a nurse will settle you into a bed or reclining chair and place a thin tube, called a catheter, into a vein in your neck.
2. The catheter will be connected to a machine that looks similar to a dialysis machine.
3. The machine draws your blood in through one of the tubes connected to the catheter, where it extracts T cells and then returns the blood to your body.
4. During the procedure, a nurse will monitor you for side effects. You may feel some numbness, tingling, or muscle spasms, likely caused by a drop in calcium levels, which is common during leukapheresis. If this happens, you may be given calcium orally or through an IV to offset the effects.
5. Once enough T cells have been extracted and your blood has been returned to your body, the nurse will remove the catheter and apply a bandage where it was inserted. The area will bleed a bit, so you’ll be instructed to keep pressure on it for three to five minutes.
6. The entire process will take about two to four hours. You’ll likely feel tired afterward, which is why you’ll need your designated caregiver to take you home. 

Once the T cells are collected, they’ll be sent to a lab to be genetically engineered and packaged into a medication that you’ll later receive by infusion. This will take four to six weeks, during which:

1. A technician will add a special receptor, called a chimeric antigen receptor (the “CAR” in CAR T-cell modification), to the T cells.
2. The modified T cells will be multiplied in the lab over the course of four to six weeks.
3. When enough T cells have formed, they’ll be prepared as an infusion and sent back to the treatment center.

A few days before the modified-T-cell infusion, you’ll receive infusions of two chemotherapy medications — cyclophosphamide and fludarabine — to prepare your body. You’ll get them once a day, for three days in a row. The goal of these sessions is to deplete some of the white blood cells to make room in your blood for the CAR T cells. After the third session, you’ll have two days of rest before the T-cell infusion.

Each day of chemotherapy will be basically the same:

1. After you arrive at the treatment center and check in, a doctor or nurse will bring you into an exam room to check your vitals. They’ll also have you step on a scale, as the dose of medication will be based partly on your weight.
2. Next, you’ll be taken into the infusion area and settled into a comfortable chair. A nurse will insert an IV into a vein in your arm.
3. The two chemotherapy drugs, which will be mixed together in an infusion bag, will flow directly into your bloodstream through a tube connecting the bag to the IV. It will take about 30 minutes for the bag to empty.
4. When the infusion is finished, the nurse will remove the IV from your arm, and your caregiver will be able to take you home.

After a day or two of rest following the chemotherapy, you’ll go to the hospital for the infusion. The actual procedure will only take about an hour, but because your healthcare team may need to monitor you for about a week or so afterward, you’ll stay in the hospital during that time. Here’s what to expect.

1. A week or two before the T-cell infusion, you should have had a pretreatment evaluation appointment. During the evaluation, your doctor and nurse coordinator should have reviewed the treatment plan with you.
2. The day of the infusion, you’ll arrive at the hospital and check in. 
3. After you’re settled in your room, a nurse will come around to connect you to an IV pole, which will be with you for most of the hospital stay. 
4. Once the infusion is ready, a member of the healthcare team will put a central venous catheter (CVC) in one of the larger veins in your body, in either an arm or your upper chest. The medication, as well as fluids, electrolytes, and blood transfusions, will be administered through the CVC.
5. Once the catheter is in, you can sit back and relax for the next 30 to 60 minutes, while the medication flows directly into your bloodstream.
6. During this time, the team will check your vitals (blood pressure, heart rate, etc.) and draw some blood to check your white and red blood cell counts.
7. After the infusion is over, the nurse will take out the CVC and monitor you for side effects.
8. You’ll likely stay in the hospital for about a week, so your healthcare team can continue to monitor you and treat any side effects that may occur. Your caregiver will need to be on hand throughout this time and for a few weeks after you’re discharged, to provide extra monitoring and support.

Sometimes the infusion is given as an outpatient procedure. In that case, you’ll still need to be monitored by a care team and may need to be admitted to the hospital if you develop side effects.