Optimization of Older Adults by a Geriatric Assessment-Guided Multidisciplinary Clinic Prior to CAR T-Cell Therapy

The optimal means of assessing candidacy of older (≥65 years) adults for CAR T-cell therapy (CAR-T) are unknown. We explored the role of a geriatric assessment (GA)-guided multidisciplinary clinic (GA-MDC) in selecting and optimizing older adults for CAR-T. From 12/2017 – 4/2022, 61 patients were evaluated in a GA-MDC (median age, 73 years; range, 58-83). Most common diagnoses were NHL (n=42) and multiple myeloma (n=14). A non-binding recommendation (‘Proceed’ or ‘Decline’) regarding suitability for CAR-T was provided on each patient based on GA results. Fifty-three patients ultimately received CAR-T (Proceed=47, Decline=6). Among patients who received BCMA-directed (n=11) and CD19-directed (n=42) CAR-T, median OS was 14.2 months and 16.6 months, respectively. GA uncovered high rates of geriatric impairment among patients proceeding to CAR-T, with fewer impairments in those recommended ‘Proceed’. Patients recommended ‘Proceed’ had shorter median length of stay (17 vs 31 days; p=0.05), lower rates of ICU admission (6% vs 50%; p=0.01) and were less likely to require rehabilitation services after discharge (11% vs 67%; p=0.01) than those recommended ‘Decline’. In patients receiving CD19- and BCMA-directed CAR-T, a ‘Proceed’ recommendation was associated with superior OS compared to ‘Decline’ (median 16.6 vs 11.4 months, p=0.02 and median 16.4 vs 4.2 months, p=0.03, respectively). When controlling for Karnofsky performance status, CRP and LDH at time of lymphodepletion, the GA-MDC treatment recommendation remained prognostic for OS (HR 3.26; p=0.04). Patients optimized via the GA-MDC without serious vulnerabilities achieved promising outcomes while patients with high vulnerability experienced high toxicity and poor outcomes following CAR-T.