How I Treat: Selecting CD19 Targeted Immunotherapies in Adult Patients with Advanced Acute Lymphoblastic Leukemia.

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CD19-targeted immunotherapies have drastically improved outcomes for patients with relapsed/refractory (r/r) B-cell acute lymphoblastic leukemia (ALL). Such therapies, including blinatumomab and CD19 chimeric antigen receptor (CD19CAR) T-cells, yield high rates of remission and can bridge to more definitive consolidation therapy with curative intent. Both treatments are FDA approved for r/r ALL (CD19CAR T-cell approval is restricted to patients {less than or equal to}25 years old). Although the availability of blinatumomab and CD19CAR T-cells have extended options for the treatment of r/r ALL, it may be difficult for the treating physician to prioritize the sequence of these agents on an individual-patient basis. It is necessary to consider the advantages, limitations, and challenges of each therapy when choosing between them. While patients may receive both blinatumomab and CD19CAR T-cells sequentially in cases that fail to respond or subsequently relapse, a proportion of patients treated with CD19-targted immunotherapy will lose expression of CD19 and will be excluded from receiving the alternative CD19-targeted therapy. Thus, it is crucial to weigh all considerations for each patient before selecting a CD19-targeted immunotherapy. Here, we discuss real life scenarios of adults with r/r ALL in which we selected either blinatumomab or CD19CAR T-cell therapy, and the rationale behind each decision.

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