The following case study demonstrates the careful coordination, collaboration, and expertise that allows Duke Cancer Institute to overcome occasional setbacks and ensure patients receive the advanced treatment they need as efficiently as possible. It is this commitment to excellence and the patient experience that has made Duke a leading provider of some of the most advanced cellular and gene therapies available today.

The patient is a 71-year-old female from Asheville, North Carolina. She was diagnosed with follicular lymphoma in 2016 and had been treated with multiple lines of therapy. When her lymphoma recurred in 2024, the patient was referred to Duke, where she underwent an autologous stem cell transplant. Ten months after her stem cell transplant, a PET scan and biopsy unfortunately confirmed disease recurrence once again. In July 2025, her local oncologist referred her back to Duke to be evaluated for CAR T-cell therapy.

Duke hematologic oncologist Alexandra Stefanovic, MD, evaluated the patient and approved her for CAR T-cell therapy after a careful review of her history, disease and functional status, as well as her family support system. Then, a dedicated nurse coordinator, Lauren Jones, RN, worked with the patient financial coordinator to obtain insurance clearance. The commercial health insurance plan required lab work, imaging, and biopsy results prior to approval, which Jones obtained through close collaboration with the referring provider. Jones then scheduled the patient for apheresis in August.

The patient received a central venous catheter and was scheduled for apheresis at the Duke Blood Cancer Center. During the four-hour appointment, the apheresis team monitored the patient closely throughout the lymphocyte collection process to manage potential side effects, such as nausea, numbness or tingling. The patient’s blood was processed according to CAR T manufacturer guidelines, and the sample was sent to the stem cell lab to prepare it for shipment.

"Our stem cell laboratory has tremendous capacity to safely handle cell therapy products, to store them appropriately, and handle all the quality aspects that allow our program to operate efficiently, says Lin.

To help prevent disease progression during the waiting period required for CAR T manufacturing, Stefanovic worked with the patient’s oncologist in Asheville to initiate bridging therapy. The local oncology team administered chemotherapy and regularly checked the patient’s labs, keeping the team at Duke informed of her status.

Two weeks after the patient returned home for bridging therapy, the manufacturer, Bristol Myers Squibb, reported that the T cell product (Breyanzi®) did not meet specifications for commercial release due to an issue with the T-cell lineage purity. Multiple physicians from the Duke Cellular Therapy Team met to evaluate the next steps. After careful consideration, the care team decided to change course and pursue a different CAR T product and manufacturer: Kymriah® by Novartis. 

Jones, the care coordinator, worked closely with the patient’s local oncologist to help the patient navigate this unexpected shift in her treatment schedule. A second apheresis procedure was necessary to collect additional lymphocytes, but strategies for disease control and washouts for bridging therapies needed to be considered. Timing appointments appropriately was critical to ensure successful collection and to prevent any further delays or gaps in treatment. The patient returned to Duke for apheresis in mid-September and resumed bridging therapy while awaiting the new CAR T product. 

"It usually takes about four weeks for a patient to get from apheresis to CAR T infusion. However, CAR T delays and manufacturing failures, while rare, can still happen given how complex and personalized the process is. A strong and coordinated team, one that can quickly adapt, communicate clearly, and work through unexpected problems together really makes all the difference. It’s this shared expertise and commitment that helps keep the care on track and support the best possible outcomes for patients, even when things don’t go exactly as planned," says Lin. 

In mid-October, once the Kymriah CAR T product was successfully manufactured, the patient returned to Duke for pre-treatment clearance. Stefanovic reviewed the patient’s blood counts, checked for signs of infection, and assessed her overall health. The patient was experiencing fatigue and lack of appetite as a result of the bridging therapy, but she was strong enough to move forward with treatment.

The patient was scheduled to begin the first phase of CAR T treatment at the Duke Day Hospital on October 24. She received lymphodepleting chemotherapy to suppress the immune system over the course of three days. Then, after two days of rest, she returned to the Day Hospital for the CAR T infusion. After the infusion, the specialized care team monitored the patient for side effects and reactions, providing medication to control nausea. 

The patient returned to the Day Hospital daily for three weeks after the infusion for follow-up. She experienced continued weakness and nausea, which were managed with fluids and medication, but no other side effects. The patient was cleared to return home four weeks after the CAR T infusion.

Lin explains, "Our Day Hospital allows us to care for patients in a way that’s both safe and convenient. It’s an advanced outpatient infusion facility open 365 days a year, so patients can come in as needed without waiting for an appointment or being admitted to the hospital. They’re able to be seen daily by a medical provider and consult with a specialized pharmacist all in one place. The team can administer IV antibiotics, tocilizumab, and other supportive treatments on-site, allowing for close monitoring and mimicking hospital-level care, while allowing patients to return to the comfort of their home each night."

Jones worked with the patient to secure convenient temporary housing during her treatment, which was funded by the CAR T manufacturer. The patient also worked with in-house physical and occupational therapists to restore her strength and mobility.

In January 2026, 90 days after CAR T-cell therapy, the patient returned to Duke for evaluation. A PET scan revealed no evidence of metabolically active lymphoma, and she remains in remission.