The European Commission has granted approval to axicabtagene ciloleucel (axi-cel; Yescarta) for the treatment of adult patients with diffuse large B-cell lymphoma (DLBCL) and high-grade B-cell lymphoma (HGBL) who experience relapse within 12 months of completing first-line chemoimmunotherapy or are refractory to it. This decision marks a significant advancement in the treatment landscape for these aggressive lymphomas.
The approval is rooted in the findings of the pivotal phase 3 ZUMA-7 trial (NCT03391466). The study compared axi-cel to the standard of care (SOC), which includes platinum-based salvage chemotherapy followed by high-dose chemotherapy and autologous stem cell transplant for those who respond to the salvage regimen. At a median follow-up of 2 years, axi-cel demonstrated a significant improvement in the primary endpoint of event-free survival (EFS) compared to SOC (HR, 0.40; 95% CI, 0.31-0.51; P < .001).
The median EFS was 8.3 months (95% CI, 4.5-15.8) in the axi-cel arm versus 2.0 months (95% CI, 1.6-2.8) in the SOC arm. Furthermore, the 2-year EFS rate was 41% (95% CI, 33%-48%) with axi-cel compared to 16% (95% CI, 11%-22%) with SOC.
Key Trial Results and Patient Outcomes
The ZUMA-7 trial's results highlight the potential of axi-cel to transform the treatment paradigm for relapsed or refractory LBCL. According to John Gribben, professor of medical oncology at the Cancer Research UK Barts Centre in London, "In ZUMA-7, treatment with [axi-cel] resulted in an overall better outcome for patients than SOC, especially in terms of EFS, marking a new era for treatment earlier in the disease pathway for more patients."
Subgroup analyses revealed that axi-cel improved EFS across various key patient subgroups, including elderly patients (HR, 0.28; 95% CI, 0.16-0.46), primary refractory patients (HR, 0.43; 95% CI, 0.32-0.57), those with HGBL (HR, 0.28; 95% CI, 0.14-0.59), and patients with double-expressor lymphoma (HR, 0.42; 95% CI, 0.27-0.67).
Safety and Quality of Life
The safety profile of axi-cel in the ZUMA-7 trial was consistent with previous studies. Among the 170 patients treated with axi-cel and evaluable for safety, grade 3 or greater cytokine release syndrome (CRS) and neurologic events occurred in 6% and 21% of patients, respectively. Notably, there were no grade 5 CRS or neurologic events. In the SOC arm, 83% of patients experienced grade 3 or greater events, primarily cytopenias.
Patient-reported outcomes (PROs) also favored axi-cel. An analysis of 165 patients showed statistically significant improvements in quality of life (QOL) at day 100 compared to the 131 patients who received SOC. These improvements were observed across three PRO domains: EORTC QLQ-C30 Physical Functioning, EORTC QLQ-C30 Global Health Status/QOL, and EQ-5D-5L visual analog scale (VAS). Additionally, there was a trend toward faster recovery to baseline QOL with axi-cel compared to SOC.
Implications for Treatment
This approval signifies a major shift in the treatment of LBCL following the failure of initial therapy. As Christi Shaw, chief executive officer of Kite, stated, "Today’s approval marks an important step by providing patients in Europe this option of CAR T-cell therapy earlier in their treatment journey."
The ZUMA-7 data has also enhanced the understanding of this CAR T-cell therapy, enabling better management and prevention of adverse effects. This is particularly important as the treatment moves earlier in the disease pathway and for older patients or those with medical conditions for whom standard of care may be challenging.
