CAR T: Marketing the promise, delivering beyond the need
By John Burke, Michael Gertner, Ph.D., and Andrea Weiss
As pharma marketers, we strive to be patient-centric. We create and analyze patient journeys, conduct in-depth research, and even co-create materials, all with the focus of creating personalized, engaging campaigns that empower and educate patients.
Sometimes, though, the science takes a leap of such breadth and scale that it changes the very concept and meaning of patient-centricity. Such is the case with CAR T therapy. The first CAR T, developed by Novartis for pediatric patients with B-cell precursor acute lymphoblastic leukemia, was approved in 2017 after the clinical trial produced astonishing results. Since then, five more CAR Ts have been approved by the FDA. Many more are in pipelines today, and the space is rapidly evolving with manufacturers exploring novel techniques, including leveraging gene-editing technology and transcriptomics to enhance the treatment and expand its use beyond oncology.
For patients used to more traditional treatments, CAR T offers an extraordinary and unique glimpse of a more hopeful future of oncology care. Alongside that new future will come a new kind of patient experience, an experience that stretches far beyond traditional ideas of treatment to include every step in the journey – the journey, in fact, is the treatment. And that will mean an entirely new approach to the promotion of CAR T brands.
One key angle to consider with CAR T is that it is a high-stakes therapy. CAR T isn’t currently indicated as a first-line therapy; patients who get to CAR T have already probably been through multiple rounds of chemotherapy and other more traditional cancer treatments. It’s expensive – about half a million dollars for the CAR T itself, and up to a million dollars when including the total cost of care – though that will hopefully decline over time. Currently, CAR T can only be administered at a limited number of major cancer centers and might require the patient to travel away from home for days or weeks at a time. However, its potential to cure certain forms of cancer makes CAR T an extremely attractive prospect for healthcare professionals and their patients. For patients who’ve been on an emotional roller coaster for years, actually hearing the word cure drives up the emotional stakes. These are patients who’ve likely been through multiple cycles of hope and disappointment; they’ve heard all the superlatives before and may have reason to be a little cynical about them. But here they are being presented with something that is substantively different than anything else, something that holds out genuine hope for the future.
Another differentiating characteristic of CAR T compared with more traditional cancer treatments is that it only happens once. Most non-surgical cancer treatments happen cyclically over a period of time. They are a chore, but a gradually recognizable and familiar one, to which patients have to drag themselves every month or two or three. Compared with that, the CAR T experience is like falling in love for the first time. It’s bumpy, it’s emotional, it’s confusing and frustrating, but it’s also joyful and full of promise and hope for the future. And it only happens once. That adds very much to the high emotional stakes of the treatment from the patient’s perspective, while reducing the number of potential touchpoints for the brand once the treatment itself is completed.
For all the promise that CAR T is showing, the road to treatment for patients is filled with potential pitfalls. The end-to-end process behind CAR T is complex – from identifying patients for referral to cell collection, storage, the manufacture of the therapy, and the infusion of the cells back into the patient – and companies are still working out the manufacturing kinks, which means that demand is far exceeding supply and the potential exists for delays at each step. We’ve even seen reports of some patients dying while waiting for treatment. Payers may have a variety of levels of support for CAR T, some generous, some not so much, and a variety of different and potentially confusing approaches to coverage and reimbursement as well. Potential treatment sites are highly limited geographically, mostly to the largest cancer centers in just a handful of big cities. And the innovative and complex nature of the treatment means that many care providers of all stripes – oncologists, dieticians, physiotherapists, palliative teams, fertility experts – need to be educated on what their roles might be in a patient’s CAR T journey.
A recent study of patients with diffuse large B-cell lymphoma who had received either stem cell transplant or CAR T, by Avalere Health (part of Fishawack Health), found that 21 percent reported feeling overwhelmed when details of their care journey did not adhere to what was previously communicated or their treatment plan changed with limited notice. Additionally, 29 percent said that their physicians were not equipped to address ancillary health concerns like mental health. So, for all of CAR T’s promise, it would be very easy for patients and healthcare professionals to have a negative experience and come away with a bad taste, even if the treatment is effective.
All this means that brand communicators for CAR T brands must consider very carefully what our responsibilities are and consider the convoluted emotional and physical patient journey. The patient is not going to the local infusion center. They’re very likely taking a train or a plane to a new environment with new care providers. They are going to be poked and prodded and observed and uncomfortable over multiple weeks and possibly multiple locations. Their cells will be harvested and “edited” and put back in just the right way. As the treatment experience is so unique (unlike that of a pill or injectable), it is important to recognize that the entire experience from cell collection to re-infusion can be considered as the brand experience. Or, put another way, the entire journey is the treatment. And establishing what a brand really is when it isn’t a pill or an injection or a traditional infusion but an actual journey, that represents a real paradigm shift for the brand manager.
A complex marketing dynamic
To properly support a CAR T brand, healthcare marketers and communicators will have to educate themselves and re-think their approaches just as much as HCPs will. When something is just a pill or just an injection or just an infusion, just take it off the shelf and get it into the patient somehow, well, those are reasonably familiar to the average human, no matter how extraordinary the effects of the pill or the injection or the infusion might be. The audience has a frame of reference. But here the marketer’s task is very different. Here the sheer complexity of the journey means we have that many more opportunities to offer support to the patient, HCP, and treatment center – but also that many more stops along the way where the patient can feel lost, devoid of information, stuck.
For HCPs, choosing the right CAR T for their patient involves reviewing data on safety and efficacy, the profile of the patient, and the benefits of the product against the competition. In addition to all that, though, they also must review the entire process to understand which brand offers the smoothest delivery of the treatment. HCPs are not only choosing a therapy, they are choosing a process, and this makes the marketing of a CAR T unique. HCPs need to feel confident in the manufacturer’s ability to produce the treatment on time, minimizing delays for the patient, and trust the company’s ability to provide support processes and manage logistics. This means that the marketer’s role must expand to building confidence and trust in the process as well as in the therapy itself.
Marketers are always tasked with meeting any patient with the right message in the right place on their journey, but here we are dealing with two significant challenges: patients who’ve likely taken a beating and may be running low on hope, and a treatment that’s outside the scope, in a variety of ways, of anything they’ve ever encountered before. So rather than educating these patients about their particular cancer – they probably already know more about it than they ever wanted to know – our task needs to be empowering them to pursue CAR T therapy, educating them about the journey they are taking with CAR T, and staying with them all along that journey.
To do that, we as brand communicators need to learn and understand all the complexities of that very literal journey in excruciating detail, if we are to communicate and drive awareness and education about it. We need to soften the patient’s fears and manage their expectations. We need to understand the discomfort of being in a new place with new people, far away from home, for a treatment that is barely understandable to the ordinary person. And we need to offset that discomfort with the hope, and the sense of being a part of something extraordinary, that comes alongside such an extraordinary innovation. Receiving CAR T therapy today is like receiving penicillin in 1944 or receiving one of the recently developed gene therapies for a life-threatening rare disease. While it isn’t quite brand-new anymore (CAR T has been around since 2017), each patient is still clearly part of something big and transformative that will save lives in ways that they couldn’t have been saved before. And that sense of the new and extraordinary ought to be elevated in all our communications.
A trusted companion
All this means that the voice of the brand can and should become a trusted companion along the rather exotic CAR T patient journey. We as brand communicators must draw a careful picture for each patient of what the CAR T experience will look and feel like, from the very beginning of the process or even before. We must soften the edges of the high science so patients can understand it. We must find the proper touchpoints, before, during, and after, since they won’t be the same as with more traditional cancer treatments. Education and support and expectation management will have to happen both as early as possible and as late as possible, which will require a rethinking of investment and resource allocation as compared with traditional oncology treatments. But that new investment is absolutely mandatory.
A treatment as personalized as CAR T is going to require highly personalized communications. Brands are going to have to develop omnichannel experiences that keep patients and healthcare professionals informed and supported with relevant content at every stage of the journey. For example, a brand might keep patients and HCPs updated on the manufacturing process at each stage of the journey, offer stories and advice from past CAR T patients and peers, develop services providing mental health support, and help out with navigating insurance and reimbursement. Indeed, several of the major pharma companies that have already commercialized a CAR T product, including Novartis, Kite/Gilead, Janssen, and BMS, have already done this to some degree. But it is critical to take the learnings of the past and apply them to the undertakings of tomorrow. That first generation of CAR T patients are a critical resource; enough folks have already been through the treatment that we have people who can tell us what needs and expectations were and weren’t met and provide perspective for the next generation. Including these CAR T “alumni” at different stages of the journey to drive improvement is critical – from involving them in clinical trial design to embedding them in the development of patient education and support materials. Their insights are invaluable. All in all, the brand ought to act as a collaborative, caring partner from the very first discussion and consideration of CAR T all the way through to the treatment itself and beyond.
We aren’t just responsible for educating and preparing the patients, either. Everyone in the healthcare world should be aware of the disparities many patients face, such as disparities of race and income and education. And here we have a treatment that even some doctors might not understand fully. It’s not hard to imagine a doctor keeping CAR T off the table if they judge, maybe unconsciously, that a particular patient just won’t understand it well enough to sign on and make the commitment. And many doctors who aren’t near a major cancer center might not consider the possibility of CAR T, or even know very much about it. One recent study published in Cancer Medicine found that more than 85 percent of CAR T patients live in metropolitan counties; the same study also found that about 67 percent of CAR T patients are white, compared with about 58 percent of the U.S. population in the 2020 Census. Let’s get real here – everyone has an immune system, everyone has a right to access any and every treatment that might save their life. While many of the barriers preventing equitable access to treatment are due to the accessibility of infusion centers and the cost of treatment, marketers still have an important role to play in limiting healthcare disparities. It’s our job as brand communicators to be trusted companions to the gatekeepers too, to educate the doctors and nurses and other HCPs, to make sure the brand itself can reach patients of every race, ethnicity, gender, income, and geographic location, to empower all potential patients so they are aware of CAR T and know to ask about it.
The bottom line here is that everything about CAR T is different than anything else anyone in our world has seen before, in a whole variety of substantive ways. The science is different, the delivery is different, the patient journey is different, the expectations are different, and so our role as brand communicators must be different as well. We cannot assume that potential CAR T patients – or doctors, for that matter – have any prior basis for understanding these potentially frightening and life-saving differences. So our traditional role as educators and supporters will be profoundly magnified in significance, and we must meet the challenge of that magnification with greater understanding, greater support, greater investment, greater vision. CAR T is in fact transformative. So we must be as well.
John Burke is senior VP of strategy; Michael Gertner, Ph.D., is senior scientific director; and Andrea Weiss is senior VP, client services, Fishawack Health.
Bonus content: CAR T explained
|By Joshua Slatko • [email protected]|
What is CAR T?
Chimeric Antigen Receptor therapy (CAR T) therapies go beyond harnessing the immune system. They contain actual T cells extracted from either a diseased patient or a healthy donor, which are then re-engineered through the addition of a chimeric antigen receptor (CAR). The CAR enables the T cell to recognize and target cancer cells, leading to their destruction. Millions of these CAR T cells are grown in a laboratory and infused back into the patient.
Different cancers have different antigens, so each CAR is designed for a specific cancer antigen, such as CD19 for certain types of leukemia or lymphoma. In this example, the CAR T therapy binds to the CD19 antigen to eliminate the cancer cells.
The CAR T therapies on the market today are all autologous (from diseased patients), but manufacturers are also looking at off-the-shelf allogeneic CAR T therapies (from healthy donors). Currently, CAR T is only used to target blood cancers, however, researchers are investigating its role in targeting solid tumors.
How does CAR T work?
The process behind autologous CAR T development and infusion is complex and multifaceted: