CAR-T: from Lab to Life

How IITB’s innovators are redefining cancer treatment in India

Cancer is one of the world’s deadliest and most complex diseases to cure. Several countries, including China, the USA, Canada, and Germany have successfully developed CAR-T (Chimeric Antigen Receptor T-cell) therapy, a type of cancer immunotherapy for destroying a patient’s cancer cells. Inspired by that, Dr. Rahul Purwar (Professor at BSBE department in IITB), Dr. Atharva Karulkar and their team at ImmunoACT, which is their start-up company, have become successful in their mission to develop CAR-T therapy against B-cell leukaemia in India. Their preliminary research has its roots here at IIT Bombay. Explaining the treatment in one line, the patient’s T-lymphocytes (a type of WBC) are modified and injected back into the blood as part of this therapy. ImmunoACT is India’s pioneer in developing the country’s first indigenous Cell & Gene Therapy. However, their most astonishing achievement is not just to develop the therapy but to make it available at a cost of approximately 10% of its American counterparts. This and owing to lesser side effects, this treatment has been shown to have a high success rate.

Recently, The Hon’ble President of India, Smt. Draupadi Murmu visited IIT Bombay on 4th April 2024, to launch the CAR-T Cell therapy in India.

“The therapy being launched today is, of course, a major step, in fact, a new milestone in the journey of healthcare innovation in India. It puts us on the global map of advanced medical care as well as on the elite list of countries which have access to this platform.”

-Hon’ble President Smt. Droupadi Murmu

Insight had the opportunity to interview Dr. Atharva Karulkar, the Co-Founder and Head of Scientific Affairs of ImmunoACT. An alumnus of IIT-Bombay from the Department of Biosciences and Bioengineering (BSBE), he initially joined as an M.Sc. student. He went on to continue to do a PhD under the guidance of Prof. Rahul Purwar. He mentioned how, from his early years, he wanted to help the patients and contribute to the medical world, but not getting into MBBS led him to pursue a B.Sc. He didn’t have a clear goal in his mind yet, till he developed a growing interest in immunology.

 “It brought me closer to patient-related work, and I was more into that type of biotech rather than engineering, sensors, technology”.
– Dr Atharva

The turning point came when he was looking for a project for his MSc dissertation.

“I somehow ended up in Rahul sir’s lab to find a research project, and that’s when he told me for the first time about something called CAR-T therapy. It was still at a very initial phase, and there was a lot to do”, Dr. Atharva told us when asked about how he came to know about CAR-T. After working in the immunobiology lab for six months, he decided to continue this endeavour for his Ph.D.

Here are a few excerpts from our interview with him.

How did it all begin? 

The journey began when Prof Rahul Purwar returned from Harvard Medical School and joined IITB as a professor at the department of BSBE in 2013. Prior to that, he was working on T-cell immunotherapy there. It was his vision to develop a similar therapy here in India.

What peak moment of your journey would you like to share? 

The moment we all got the most significant push in our journey was when the first CAR-T was approved in the United States in 2017. The treatment cost was around 400,000 USD, roughly three to four crores INR. From there onwards, the product development accelerated with the mindset that if a country on some other continent could achieve it, so could we. However, we knew we had to reduce costs to make it accessible for the average Indian.

How are CARs made?

The process of making a CAR-T cell can be divided into three parts. The first part involves creating the plasmids containing the DNA that expresses the gene of interest. The second part is making the lentiviral vector, a gene delivery vehicle similar to a viral vaccine, where the DNA is packaged and delivered into CAR cells. The third part is the actual production of CAR-T cells.
(Detailed explanation is given in the footnote¹)

We had to master these steps, and all of this work was done in-house in our lab. To this day, we don’t outsource any part of the process.

What were some of the major roadblocks in your journey? 

The biggest roadblock we had was the lack of a precedent in India. When it’s doing research in your own lab, generally, you have the work of previous PhD students from the last few years or so as a reference, with some background material to build on and the techniques they used. For us, however, everything was based on research available online. We relied solely on papers published by companies and universities in the US, trying to understand and replicate their efforts. We had no precedent and no seniors to consult for experimental help. We were entirely on our own.

Initially, we started with a biosimilar approach, using approved CARs as our positive control² to establish a foundation and determine if this technique would work for us. Our new product was quite different, but we needed to understand the basics first.

We utilised online patent sequences, synthesised them, and verified that these CARs worked because existing data confirmed their efficacy in patients. The idea was to replicate these CARs in our lab to establish a reliable method for creating CAR-T cells.

Another challenge we faced was ensuring that our methods could be scaled up in India. We didn’t want to rely on fancy techniques or reagents that wouldn’t be accessible later. We had to devise scalable solutions from the start.

A significant drawback of CAR-T therapy in the US is that a large number of patients suffered and ended up in ICU following problems like cytokine release syndrome and neurotoxicity. Implementing this in India was also difficult due to insufficient health infrastructure, as seen during the COVID-19 pandemic.

At that time, there was no company but just a PhD project and academic research. It was during this phase that the Tata Memorial Centre came in and collaborated with us. This partnership was crucial in moving our work forward.

Can you brief us about your collaborations?
We realised early on that we couldn’t do everything on our own and needed external expertise to grow faster.

Tata Memorial Center (TMC), known for pioneering cancer treatments in India, has extensive experience with novel therapies. TMC heard about our project and decided to collaborate with us, which provided an additional push. Two doctors at the Tata Memorial Centre believed in our potential to create something beneficial for patients. At that time, everything was still on paper with no tangible product, but their confidence in our hard work was encouraging, and they wanted to be associated with our efforts.

There was always a need for CAR-T therapy for patients at TMC, and we were tasked with meeting that need. Additionally, we were introduced to the National Cancer Institute (NCI) in the United States, the pioneering institution for immunotherapy. We had great experts like Dr. Nirali Shah and Dr. Steven Rosenberg on our advisory board.

When our experiments faced challenges, we reached out to these experts for insights and guidance. Their advice was invaluable in ensuring that our experimental plans were on the right track. Dr. Alka, then a post-doctoral fellow from Prof. Purwar’s lab who was on our team, visited NCI, where she learned about their methods. Upon returning, we corrected our mistakes based on her insights. This marked a turning point around 2017-2018 when we finally had something that seemed to be working.

While developing the CAR-T manufacturing process, we were also simultaneously creating our own CAR-T construct. This construct involved a synthetic gene, which is the core of our intellectual property and patent. Since this gene doesn’t occur naturally, we had to design it from scratch.

How was ImmunoACT started?

ImmunoACT finally came into the picture in 2018, when we realised that what we aim for can’t be achieved by just an academic research project but by an enterprise which can scale up the idea. When we had this idea, we approached the CEO of SINE at IIT Bombay, who helped us establish the company. As students and scientists, we weren’t familiar with the process of forming a company. SINE guided us through crucial steps, like team structure, business plan development, incorporation, audit requirements, and connecting with industry experts to evaluate our work’s viability.

SINE also provided our initial funding of five lakh rupees and a space in the Monash building, where we set up our first lab. This support was a significant milestone for us. Essentially, SINE helped transform our ideas into a viable business, teaching us how to pitch our startup and focus on product marketing beyond just the scientific aspects.

We conducted our phase one clinical trial at IIT Bombay in 2018, funded mainly by BIRAC (Biotechnology Industry Research Assistance Council) and Tata Trusts, thanks to our collaboration with TMC. Tata Trusts supported us in creating a GMP³ (Good Manufacturing Practice) facility at IIT Bombay. This allowed us to transition from making products in a Petri dish to producing pharmaceutical-grade products in a cleanroom environment. After successful phase-one trials with excellent safety profiles, we licensed our technology to ImmunoACT. Subsequently, Laurus Labs from Hyderabad invested significantly in the project. This enabled us to establish a 15,000-square-foot manufacturing facility in Rabale, Mumbai, where we continue manufacturing. In 2022, we started and completed our phase two trials, receiving market authorisation in 2023. Now, in 2024, we are in our first revenue year. Laurus Labs further invested in the company, increasing its stake by 7% due to our rapid growth and successful commercialisation. Today, the company has over 100 employees and is valued at around 1,000 crore rupees.

How is CAR-T therapy different from a chemical drug, and why was it challenging to regulate and adopt?

The first child who was cured with CAR-T therapy in the United States still has it in her blood, and it’s more than 12 years. This is entirely different from a chemical drug that typically washes away from the body in a maximum of 1 week and does not remain in the patient’s body indefinitely. Instead, it is a living medicine.

The regulatory framework had to adapt to accommodate this new technology of a living drug. For instance, schedule M⁴ of India’s drug manufacturing laws, previously did not include cell therapy. However, a new set of guidelines are released for the Gene Therapy development and Clinical trials.

Also, CAR-T therapy is not about bulk manufacturing but personalised medication, meaning each product is made specifically for each patient. When we started, there were no established guidelines for such personalised treatments in India, as the focus had been on chemical drugs and monoclonal antibodies. We had to work with regulatory bodies like RCGM⁵ and CDSCO⁶ to develop appropriate protocols and ethical guidelines. These bodies were also learning mutually with us, as CAR-T therapy was a new frontier.

How did you achieve the cost reduction of 90%?

Let’s discuss the various factors affecting the cost.

The first factor is the therapy’s personalised nature. It has to be prepared separately for each patient and not manufactured in bulk, so it automatically brings the expense up. The second cost is sourcing the viral vectors and plasmids. Many companies outsource them, but the delay (around 1.5 years) and dependency increases the price by 20-30%. So we decided to make our own vector to cut that down. Another factor is the manpower cost. In the U.S., the high cost of skilled labour, due to socioeconomic factors, significantly increases expenses. However, in India, the cost of skilled manpower is more economical compared to the USA, and we were able to save about 60% due to that. 

How can a patient get treated with CAR-T? 

We have partnered with over 40 hospitals across the nation, including rural hospitals, private chains like Apollo and Fortis, and top government cancer centres, to make CAR-T therapy accessible to all segments of society.

These hospitals directly contact patients, and we are only the manufacturers. The hospital doctors evaluate the patients based on some approved criteria, which we educate the staff about during onboarding sessions. Once a patient is deemed eligible for CAR-T treatment, the hospital notifies us, and we allocate a production slot to get the sample. Due to insurance approvals, we aim to deliver CAR-T therapy within 20 days, much faster than the typical four to five weeks in the Western world.

We also offer a patient support program for the financially burdened, providing discounts to prioritise access to therapy overpayment and ensuring that we help those in need.

What were Professor Purwar’s Contributions to the endeavour?
Professor Rahul Purwar has always been a guiding force in our journey, driven by his clear vision of focusing on science for society rather than commercial success. His commitment to scientific excellence and integrity has been our foundation.

His foresight has been instrumental in our achievements, involving critical decision-making and taking risks. He inspired us to think beyond immediate academic goals and consider how our science can benefit society. He was the one who secured crucial collaborations with Tata Memorial Center and NCI, demonstrating his dedication and hands-on involvement.

Professor Purwar’s commitment went beyond guidance; he actively participated in experiments, especially when we faced challenges, ensuring that we stayed on track. His willingness to work alongside us in the lab showcased his dedication and belief in our potential. Without his support, we wouldn’t have reached where we are today.

Moving Forward: What are your future plans?

We have plans to expand our domain both horizontally and vertically. Horizontally, we are trying to increase the reach of the product to different states in India and across the globe; for instance, we recently signed an MoU with the government of Mexico. We are targeting countries with similar economies, like India, where there is a need for CAR-T therapies, like African and European ones. We will tie up with some local pharma companies there, which will assist in the provision and logistics.
Vertical expansion is when we try to expand our portfolio and develop products for other diseases. Right now, NexCAR19, which is the first product of ImmunoACT, is used for the treatment of Lymphoma and Leukaemia. Still, we’re actively engaging with the stakeholders to develop CAR-Ts for non-oncology indications. Now we are trying to move beyond cancer – there’s sickle cell anaemia and other diseases, where immune cells can help in providing therapeutic effects.

What is your final advice to upcoming researchers?
I graduated with a PhD from IITB in 2021, so I am too young to give advice. However, what has worked for me is seeing things through to the end. Instead of viewing my work as just an MSc or PhD project, I treated it as a dedicated activity that I needed to take to its final point. This mindset helped me persevere and avoid the temptation to drop out after my PhD and work somewhere else instead of starting up. It’s crucial not just to aim to get the work done but to think about how much you can contribute. Understand the bigger picture and the long-term impact of your work. For instance, when my experiments didn’t work, I had to remind myself that it could mean the difference between life and death for a patient. Keeping this in mind can provide inspiration and motivation to keep pushing forward.

Editorial Credits: Adarsh Prajapati, Jayesh Kamath

Footnotes:

¹ In CAR T-cell therapy, T cells derived from either patients (autologous) or healthy donors (allogeneic) are modified to express CAR. This chimeric construct combines antigen binding with T-cell activation to target tumour cells. Lentivirus CAR expression vector is a highly efficient viral vector tool for delivering second-generation CAR expression cassettes into T cells. The lentivirus CAR expression vector is first constructed as a plasmid where the entire CAR expression cassette is cloned in between the two long terminal repeats (LTRs). It is then transfected into packaging cells along with several helper plasmids. In the packaging cells, vector DNA between the two LTRs is transcribed into RNA, and viral proteins expressed by the helper plasmids further package the RNA into the virus. Live virus is then released into the supernatant, which can be used to infect target cells directly or after concentration.

When the virus is added to target cells, the RNA cargo is shuttled into cells, where it is reverse-transcribed into DNA and randomly integrated into the host genome. Any gene(s) that were placed in between the two LTRs during vector cloning are permanently inserted into host DNA alongside the rest of the viral genome.

Information from: VectorBuilder
Other valuable links for explanation: CAR T-Cell Therapy: How Does It Work?

Lymphoma: Overview of Chimeric Antigen Receptor (CAR) T cells

² The positive control sample will show an expected result, helping the scientist understand that the experiment was performed correctly.

³ Good Manufacturing Practices or GMP is a system that consists of processes, procedures and documentation that ensures manufacturing products, such as food, cosmetics, and pharmaceutical goods, are consistently produced and controlled according to set quality standards.

⁴ Schedule M is a set of comprehensive regulations issued by GOI for good manufacturing practices and requirements of premises, plant and equipment for pharmaceutical products.

⁵ The review committee on genetic manipulation (RCGM) established under the Department of Biotechnology, Ministry of Science and Technology monitors the safety of ongoing research projects and activities (including small-scale field trials, import, export, etc) involving genetically engineered organisms.
⁶ Under the Drugs and Cosmetics Act, the Central Drugs Standard Control Organisation(CDSCO) is responsible for approval of Drugs, conduct of Clinical Trials, laying down the standards for Drugs, and control over the quality of imported Drugs in the country.

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