Due to the invention of new therapies, cancer has increasingly become a chronic disease in recent decades. This has led to an increase in overall survival in many cancers. For example, multiple myeloma (MM), a disease that can lead to death within a few months if left untreated, has been made treatable by new innovative drugs such as immunomodulatory agents, proteasome inhibitors, or CD-38 antibodies over many years.1 Chimeric antigen receptor (CAR)-T cell therapy is the latest innovation in the treatment of myeloma and other lymphoid B cell disorders, leading to further prolongation of the illness trajectory and overall survival in these chronically ill patients.

CAR-T cell therapy is a new type of immunotherapy.2 The patient's own T cells are collected and genetically modified in the laboratory with an “artificial” surface receptor that can efficiently target a specific tumor antigen (CD-19 in B cell malignancies and BCMA in myeloma). Once retransferred in the patient's body, the CAR-T cells recognize the cancer cells that carry the specific antigen. Recognizing and binding the CAR to the tumor target leads to strong immune activation, which can lead to durable remissions. The CAR-T cell therapy process may take several weeks to many months and begins with the decision about the treatment. Therefore, patients and their families should be informed and educated to foster informed consent and adherence. These factors contribute significantly to the success of the treatment. Patients may have been living with their disease for more than 400 months3, 4, 5, 6 when the decision to undergo CAR-T cell therapy was made. Following this decision, the next step in the process is the collection of T cells by apheresis. The collected T cells are then sent to a specialized laboratory to get genetically modified. Once manufactured, the CAR-T cell product is returned to the treatment center where it can be cryopreserved until the medically optimal time to reinfuse the patient. The time from apheresis to CAR-T cell reinfusion is usually about one month but can take up to 526 days.3, 4, 5, 6 During the production of CAR-T cells, patients are often subjected to bridging chemotherapy. During this period, the condition of some patients deteriorates to such an extent that they will no longer be able to tolerate the CAR-T cell infusion or will even die before it. The actual treatment then begins with lymphodepleting chemotherapy, followed a few days later by the return of the CAR-T cells. Once back in the patient's body, there is a risk of severe side effects caused by a strong immune response. These need to be carefully monitored and treated.7 The two most prevalent and serious toxicities are the cytokine release syndrome (CRS) and the immune effector cell associated neurotoxicity syndrome (ICANS)8 of which both can be life-threatening. CRS is an acute systemic inflammatory reaction that occurs after the re-transfusion of CAR-T cells. Most patients present with fever, followed by tachycardia, tachypnoea, hypotension, hypoxemia, and multiorgan failure. The onset of ICANS is usually later than that of CRS. Patients present with a variety of neurological symptoms such as aphasia, impaired consciousness, cognitive impairment, seizures, and cerebral edema. Patients are usually hospitalized in a specialized center for at least two weeks to monitor for these toxicities. Even after the inpatient phase, these toxicities can occur. For this reason, they must be monitored by a caregiver for 1 to 2 months, should not be more than an hour away from the treatment center, and should not operate heavy machinery. A number of follow-up appointments are also necessary during this time. First attempts of outpatient CAR-T cell therapy have already been conducted.9,10

Patients undergoing CAR-T cell therapy present several challenges to the treatment team. They are chronically ill patients who have had multiple prior treatments. They are often in palliative condition and have a range of 9% to 19% of patients with ECOG performance status ≥2.3, 4, 5, 6,11 Although the median age of patients undergoing CAR-T cell therapy is between 59 and 64 years, with a range of up to 90 years, this group of patients tends to be older than the patient groups previously seen in stem cell transplantation.3, 4, 5, 6,11 In addition, the therapy is difficult to carry out without the involvement of family members.

How patients can be supported in the process of CAR-T cell therapy is shown by the Chronic Care Model.12 The informed, activated patient meets the prepared, proactive practice team. Both are in a productive interaction. This will help patients to develop the self-management skills that they will need as people with chronic conditions. They need to adhere to therapies and may also need to make behavioral changes. There is a need for a co-ordinated, multiprofessional, and long-term care process to address all aspects of the chronic disease.13 Advanced practice nurses (APNs) may be the ideal professionals to initiate such a process. These challenges require all the core competencies of an APN as described by Hamric and Spross.14 (1) Guidance and coaching for the continuous support and education of patients and relatives, (2) leadership for the introduction of this innovative therapy in the treatment center, (3) consultation as an expert in the care of patients undergoing CAR-T cell therapy, (4) collaboration for the cooperation and coordination of the multiprofessional team, (5) evidence-based practice for the transfer of theory into practice and the further development of symptoms management, and (6) ethical decision making in the challenges of CAR-T cell therapy in elderly, frail, and palliative patients. The aim of this article is to identify the relevant key points of the work of an APN for patients undergoing CAR-T cell therapy from the current literature.