A recent study by researchers at the University of Pennsylvania examined how CAR-T therapy helped Doug Olson beat a cancer death sentence for over a decade - and how it could work for more people.
Doug Olson was 49 when he was diagnosed with chronic lymphocytic leukemia, a blood cancer that strikes 21,000 Americans annually. Although the disease kills most patients within a decade, Olson’s case progressed more slowly, and courses of mild chemotherapy kept him healthy for 13 years. Then, when he was 62, the medication stopped working. The cancer had mutated, his doctor explained, becoming resistant to standard remedies. Harsher forms of chemo might buy him a few months, but their side effects would be debilitating. It was time to consider the treatment of last resort: a bone-marrow transplant.
Olson, a scientist who developed blood-testing instruments, knew the odds. There was only a 50 percent chance that a transplant would cure him. There was a 20 percent chance that the agonizing procedure—which involves destroying the patient’s marrow with chemo and radiation, then infusing his blood with donated stem cells—would kill him. If he survived, he would face the danger of graft-versus-host disease, in which the donor’s cells attack the recipient’s tissues. To prevent it, he would have to take immunosuppressant drugs, increasing the risk of infections. He could end up with pneumonia if one of his three grandchildren caught a sniffle. “I was being pushed into a corner,” Olson recalls, “with very little room to move.”
Soon afterward, however, his doctor revealed a possible escape route. He and some colleagues at the University of Pennsylvania’s Abramson Cancer Center were starting a clinical trial, he said, and Olson—still mostly symptom-free—might be a good candidate. The experimental treatment, known as CAR-T therapy, would use genetic engineering to turn his T lymphocytes (immune cells that guard against viruses and other pathogens) into a weapon against cancer.
In September 2010, technicians took some of Olson’s T cells to a laboratory, where they were programmed with new molecular marching orders and coaxed to multiply into an army of millions. When they were ready, a nurse inserted a catheter into his neck. At the turn of a valve, his soldiers returned home, ready to do battle.
“I felt like I’d won the lottery,” Olson says. But he was only the second person in the world to receive this “living drug,” as the University of Pennsylvania investigators called it. No one knew how long his remission would last.
Three weeks later, Olson was slammed with a 102-degree fever, nausea, and chills. The treatment had triggered two dangerous complications: cytokine release syndrome, in which immune chemicals inflame the patient’s tissues, and tumor lysis syndrome, in which toxins from dying cancer cells overwhelm the kidneys. But the crisis passed quickly, and the CAR-T cells fought on. A month after the infusion, the doctor delivered astounding news: “We can’t find any cancer in your body.”
“I felt like I’d won the lottery,” Olson says. But he was only the second person in the world to receive this “living drug,” as the University of Pennsylvania investigators called it. No one knew how long his remission would last.
An Unexpected Cure
In February 2022, the same cancer researchers reported a remarkable milestone: the trial’s first two patients had survived for more than a decade. Although Olson’s predecessor—a retired corrections officer named Bill Ludwig—died of COVID-19 complications in early 2021, both men had remained cancer-free. And the modified immune cells continued to patrol their territory, ready to kill suspected tumor cells the moment they arose.
“We can now conclude that CAR-T cells can actually cure patients with leukemia,” University of Pennsylvania immunologist Carl June, who spearheaded the development of the technique, told reporters. “We thought the cells would be gone in a month or two. The fact that they’ve survived 10 years is a major surprise.”
Even before the announcement, it was clear that CAR-T therapy could win a lasting reprieve for many patients with cancers that were once a death sentence. Since the Food and Drug Administration approved June’s version (marketed as Kymriah) in 2017, the agency has greenlighted five more such treatments for various types of leukemia, lymphoma, and myeloma. “Every single day, I take care of patients who would previously have been told they had no options,” says Rayne Rouce, a pediatric hematologist/oncologist at Texas Children’s Cancer Center. “Now we not only have a treatment option for those patients, but one that could potentially be the last therapy for their cancer that they’ll ever have to receive.”
Immunologist Carl June, middle, spearheaded development of the CAR-T therapy that gave patients Bill Ludwig, left, and Doug Olson, right, a lengthy reprieve on their terminal cancer diagnoses.
Penn Medicine
Yet the CAR-T approach doesn’t help everyone. So far, it has only shown success for blood cancers—and for those, the overall remission rate is 30 to 40 percent. “When it works, it works extraordinarily well,” says Olson’s former doctor, David Porter, director of Penn’s blood and bone marrow transplant program. “It’s important to know why it works, but it’s equally important to know why it doesn’t—and how we can fix that.”
The team’s study, published in the journal Nature, offers a wealth of data on what worked for these two patients. It may also hold clues for how to make the therapy effective for more people.
Building a Better T Cell
Carl June didn’t set out to cure cancer, but his serendipitous career path—and a personal tragedy—helped him achieve insights that had eluded other researchers. In 1971, hoping to avoid combat in Vietnam, he applied to the U.S. Naval Academy in Annapolis, Maryland. June showed a knack for biology, so the Navy sent him on to Baylor College of Medicine. He fell in love with immunology during a fellowship researching malaria vaccines in Switzerland. Later, the Navy deployed him to the Fred Hutchinson Cancer Research Center in Seattle to study bone marrow transplantation.
There, June became part of the first research team to learn how to culture T cells efficiently in a lab. After moving on to the National Naval Medical Center in the ’80s, he used that knowledge to combat the newly emerging AIDS epidemic. HIV, the virus that causes the disease, invades T cells and eventually destroys them. June and his post-doc Bruce Levine developed a method to restore patients’ depleted cell populations, using tiny magnetic beads to deliver growth-stimulating proteins. Infused into the body, the new T cells effectively boosted immune function.
In 1999, after leaving the Navy, June joined the University of Pennsylvania. His wife, who’d been diagnosed with ovarian cancer, died two years later, leaving three young children. “I had not known what it was like to be on the other side of the bed,” he recalls. Watching her suffer through grueling but futile chemotherapy, followed by an unsuccessful bone-marrow transplant, he resolved to focus on finding better cancer treatments. He started with leukemia—a family of diseases in which mutant white blood cells proliferate in the marrow.
Cancer is highly skilled at slipping through the immune system’s defenses. T cells, for example, detect pathogens by latching onto them with receptors designed to recognize foreign proteins. Leukemia cells evade detection, in part, by masquerading as normal white blood cells—that is, as part of the immune system itself.
June planned to use a viral vector no one had tried before: HIV.
To June, chimeric antigen receptor (CAR) T cells looked like a promising tool for unmasking and destroying the impostors. Developed in the early ’90s, these cells could be programmed to identify a target protein, and to kill any pathogen that displayed it. To do the programming, you spliced together snippets of DNA and inserted them into a disabled virus. Next, you removed some of the patient’s T cells and infected them with the virus, which genetically hijacked its new hosts—instructing them to find and slay the patient’s particular type of cancer cells. When the T cells multiplied, their descendants carried the new genetic code. You then infused those modified cells into the patient, where they went to war against their designated enemy.
Or that’s what happened in theory. Many scientists had tried to develop therapies using CAR-T cells, but none had succeeded. Although the technique worked in lab animals, the cells either died out or lost their potency in humans.
But June had the advantage of his years nurturing T cells for AIDS patients, as well as the technology he’d developed with Levine (who’d followed him to Penn with other team members). He also planned to use a viral vector no one had tried before: HIV, which had evolved to thrive in human T cells and could be altered to avoid causing disease. By the summer of 2010, he was ready to test CAR-T therapy against chronic lymphocytic leukemia (CLL), the most common form of the disease in adults.
Three patients signed up for the trial, including Doug Olson and Bill Ludwig. A portion of each man’s T cells were reprogrammed to detect a protein found only on B lymphocytes, the type of white blood cells affected by CLL. Their genetic instructions ordered them to destroy any cell carrying the protein, known as CD19, and to multiply whenever they encountered one. This meant the patients would forfeit all their B cells, not just cancerous ones—but regular injections of gamma globulins (a cocktail of antibodies) would make up for the loss.
After being infused with the CAR-T cells, all three men suffered high fevers and potentially life-threatening inflammation, but all pulled through without lasting damage. The third patient experienced a partial remission and survived for eight months. Olson and Ludwig were cured.
Learning What Works
Since those first infusions, researchers have developed reliable ways to prevent or treat the side effects of CAR-T therapy, greatly reducing its risks. They’ve also been experimenting with combination therapies—pairing CAR-T with chemo, cancer vaccines, and immunotherapy drugs called checkpoint inhibitors—to improve its success rate. But CAR-T cells are still ineffective for at least 60 percent of blood cancer patients. And they remain in the experimental stage for solid tumors (including pancreatic cancer, mesothelioma, and glioblastoma), whose greater complexity make them harder to attack.
The new Nature study offers clues that could fuel further advances. The Penn team “profiled these cells at a level where we can almost say, ‘These are the characteristics that a T cell would need to survive 10 years,’” says Rouce, the physician at Texas Children’s Cancer Center.
One surprising finding involves how CAR-T cells change in the body over time. At first, those that Olson and Ludwig received showed the hallmarks of “killer” T-cells (also known as CD8 cells)—highly active lymphocytes bent on exterminating every tumor cell in sight. After several months, however, the population shifted toward “helper” T-cells (or CD4s), which aid in forming long-term immune memory but are normally incapable of direct aggression. Over the years, the numbers swung back and forth, until only helper cells remained. Those cells showed markers suggesting they were too exhausted to function—but in the lab, they were able not only to recognize but to destroy cancer cells.
June and his team suspect that those tired-looking helper cells had enough oomph to kill off any B cells Olson and Ludwig made, keeping the pair’s cancers permanently at bay. If so, that could prompt new approaches to selecting cells for CAR-T therapy. Maybe starting with a mix of cell types—not only CD8s, but CD4s and other varieties—would work better than using CD8s alone. Or perhaps inducing changes in cell populations at different times would help.
Another potential avenue for improvement is starting with healthier cells. Evidence from this and other trials hints that patients whose T cells are more robust to begin with respond better when their cells are used in CAR-T therapy. The Penn team recently completed a clinical trial in which CLL patients were treated with ibrutinib—a drug that enhances T-cell function—before their CAR-T cells were manufactured. The response rate, says David Porter, was “very high,” with most patients remaining cancer-free a year after being infused with the souped-up cells.
Such approaches, he adds, are essential to achieving the next phase in CAR-T therapy: “Getting it to work not just in more people, but in everybody.”
Doug Olson enjoys nature - and having a future.
Penn Medicine
To grasp what that could mean, it helps to talk with Doug Olson, who’s now 75. In the years since his infusion, he has watched his four children forge careers, and his grandkids reach their teens. He has built a business and enjoyed the rewards of semi-retirement. He’s done volunteer and advocacy work for cancer patients, run half-marathons, sailed the Caribbean, and ridden his bike along the sun-dappled roads of Silicon Valley, his current home.
And in his spare moments, he has just sat there feeling grateful. “You don’t really appreciate the effect of having a lethal disease until it’s not there anymore,” he says. “The world looks different when you have a future.”
COVID-19 vaccines for humans number 30, while only three vaccines are available for animals, even though many species have been infected.
“Several animal species have been predicted and found to be susceptible to SARS-CoV-2,” says Suresh V. Kuchipudi, interim director of the Animal Diagnostic Laboratory at the Huck Institutes of Life Sciences. But the risk remains unknown for many animals in several parts of the world, he says. “Therefore, there is an urgent need to monitor the SARS-CoV-2 exposure of high-risk animals in different parts of the world.”
In June, India introduced Ancovax, its first COVID-19 vaccine for animals. The development came a year after the nation reported that the virus had infected eight Asiatic lions, with two of them dying. While 30 COVID-19 vaccines for humans have been approved for general or emergency use across the world, Ancovax is only the third such vaccine for animals. The first, named Carnivac-Cov, was registered by Russia in March last year, followed by another vaccine four months later, developed by Zoetis, a U.S. pharmaceutical company.
Christina Lood, a Zoetis spokesperson, says the company has donated over 26,000 doses of its animal vaccine to over 200 zoos – in addition to 20 conservatories, sanctuaries and other animal organizations located in over a dozen countries, including Canada, Chile and the U.S. The vaccine, she adds, has been administered to more than 300 mammalian species so far.
“At least 75 percent of emerging infectious diseases have an animal origin, including COVID-19,” says Lood. “Now more than ever before, we can all see the important connection between animal health and human health."
The Dangers of COVID-19 Infections among Animals
Cases of the virus in animals have been reported in several countries across the world. As of March this year, 29 kinds of animals have been infected. These include pet animals like dogs, cats, ferrets and hamsters; farmed animals like minks; wild animals like the white-tailed deer, mule deer and black-tailed marmoset; and animals in zoos and sanctuaries, including hyenas, hippopotamuses and manatees. Despite the widespread infection, the U.S. Centres for Diseases Control and Prevention (CDC) has noted that “we don’t yet know all of the animals that can get infected,” adding that more studies and surveillance are needed to understand how the virus is spread between humans and animals.
Leyi Wang, a veterinary virologist at the Veterinary Diagnostic Laboratory, University of Illinois, says that captive and pet animals most often get infected by humans. It goes both ways, he says, citing a recent study in Hong Kong that found the virus spread from pet hamsters to people.
Wang’s bigger concern is the possibility that humans or domestic animals could transmit the virus back to wildlife, creating an uncontrollable reservoir of the disease, especially given the difficulty of vaccinating non-captive wild animals. Such spillbacks have happened previously with diseases such as plague, yellow-fever, and rabies.
It’s challenging and expensive to develop and implement animal vaccines, and demand has been lacking as the broader health risk for animals isn’t well known among the public. People tend to think only about their house pets.
In the past, other human respiratory viruses have proven fatal for endangered great apes like chimpanzees and gorillas. Fearing that COVID-19 could have the same effect, primatologists have been working to protect primates throughout the pandemic. Meanwhile, virus reservoirs have already been created among other animals, Wang says. “Deer of over 20 U.S. states were tested SARS-CoV-2 positive,” says Wang, pointing to a study that confirmed human-to-deer transmission as well as deer-to-deer transmission. It remains unclear how many wildlife species may be susceptible to the disease due to interaction with infected deer, says Wang.
In April, the CDC expressed concerns over new coronavirus variants mutating in wildlife, urging health authorities to monitor the spread of the contagion in animals as threats to humans. The WHO has made similar recommendations.
Challenges to Vaccine Development
Zoetis initiated development activities for its COVID-19 vaccine in February 2020 when the first known infection of a dog occurred in Hong Kong. The pharmaceutical giant completed the initial development work and studies on dogs and cats, and shared their findings at the World One Health Congress in the fall of 2020. A few months later, after a troop of eight gorillas contracted the virus at the San Diego Zoo Safari Park, Zoetis donated its experimental vaccine for emergency use in the great ape population.
Zoetis has uniquely formulated its COVID-19 vaccine for animals. It uses the same antigen as human vaccines, but it includes a different type of carrier protein for inducing a strong immune response. “The unique combination of antigen and carrier ensures safety and efficacy for the species in which a vaccine is used,” says Lood.
But it’s challenging and expensive to develop and implement animal vaccines, and demand has been lacking as the broader health risk for animals isn’t well known among the public. People tend to think only about their house pets. “As it became apparent that risk of severe disease for household pets such as cats and dogs was low, demand for those vaccines decreased before they became commercially available,” says William Karesh, executive vice-president for health and policy at EcoHealth Alliance. He adds that in affected commercial mink farms, the utility of a vaccine could justify the cost in some cases.
Although scientists have made tremendous advances in making vaccines for animals, Kuchipudi thinks that the need for COVID-19 vaccines for animals “must be evaluated based on many factors, including the susceptibility of the particular animal species, health implications, and cost.”.
Not every scientist feels the need for animal vaccines. Joel Baines, a professor of virology at Cornell University’s Baker Institute for Animal Health, says that while domestic cats are the most susceptible to COVID-19, they usually suffer mild infections. Big cats in zoos are vulnerable, but they can be isolated or distanced from humans. He says that mink farms are a relatively small industry and, by ensuring that human handlers are COVID negative, such outbreaks can be curtailed.
Baines also suggests that human vaccines could probably work in animals, as they were tested in animals during early clinical trials and induced immune responses. “However, these vaccines should be used in humans as a priority and it would be unethical to use a vaccine meant for humans to vaccinate an animal if vaccine doses are at all limiting,” he says.
William Karesh, president of the World Animal Health Organization Working Group on Wildlife Diseases, says the best way to protect animals is to reduce their exposure to infected people.
William Karesh
In the absence of enough vaccines, Karesh says that the best way to protect animals is the same as protecting unvaccinated humans - reduce their exposure to infected people by isolating them when necessary. “People working with or spending time with wild animals should follow available guidelines, which includes testing themselves and wearing PPE to avoid accidentally infecting wildlife,” he says.
The Link between Animal and Human Health
Although there is a need for animal vaccines in response to virus outbreaks, the best approach is to try to prevent the outbreaks in the first place, explains K. Srinath Reddy, president of the Public Health Foundation of India. He says that the incidence of zoonotic diseases has increased in the past six decades because human actions like increased deforestation, wildlife trade and animal meat consumption have opened an ecological window for disease transmission between humans and animals. Such actions chip away at the natural barriers between humans and forest-dwelling viruses, while building conveyor belts for the transmission of zoonotic diseases like COVID-19.
Many studies suggest that the source of COVID-19 was infected live animals sold at a wet market in China’s Wuhan. The market sold live dogs, rats, porcupines, badgers, hares, foxes, hedgehogs, marmots and Chinese muntjac (small deer) and, according to a study published in July, the virus was found on the market’s stalls, animal cages, carts and water drains.
This research strongly suggests that COVID-19 is a zoonotic disease, one that jumps from animals to humans due to our close relationship with them in agriculture, as companions and in the natural environment. Half of the infectious diseases that affect people come from animals, but the study of zoonotic diseases has been historically underfunded, even as they can reduce the likelihood and cost of future pandemics.
“We need to invest in vaccines,” says Reddy, “but that cannot be a substitute for an ecologically sensible approach to curtailing zoonotic diseases.”
