Overcoming Barriers: Ensuring Equitable Access to Transformative CAR T-Cell Therapy

In a world where cutting-edge cancer treatments can mean the difference between life and death, patients in certain regions face a daunting challenge: navigating the complex web of insurance restrictions and geographic barriers that can prevent them from accessing the care they desperately need. This is the reality for many individuals living in the shadow of the Delaware River, mere minutes away from a state-of-the-art cancer clinic, yet unable to receive the revolutionary chimeric antigen receptor (CAR) T-cell therapy that could save their lives.

Bridging the Gap: Unlocking Access to Transformative Cancer Treatments

Geographical Hurdles and the Burden of Travel

For patients in Camden County, New Jersey, the promise of CAR T-cell therapy may as well be a mirage, despite its proximity. Due to insurance restrictions, these individuals are required to travel more than 2 hours each way to access the treatment in New Jersey, rather than the nearby facility in Philadelphia, Pennsylvania. This arduous journey, compounded by the physical and emotional toll of cancer, can be a daunting obstacle for many, leading some to forgo the treatment altogether in favor of less effective options closer to home."You're nauseous, tired, fatigued, [and] full of uncertainties," said Usama Gergis, MD, MBA, professor of medical oncology and director of bone marrow transplant and immune cellular therapy at Thomas Jefferson University. "You're dealing with cancer, and now your state that you're paying taxes to tells you, 'No, you cannot cross the bridge and go to the transplant center 10 minutes away. You need to drive 2 hours each way in New Jersey traffic.'"

Socioeconomic Disparities in CAR T-Cell Therapy Access

Gergis and his colleagues have delved deep into the issue, examining the socioeconomic factors that determine who receives this transformative treatment. Their recent study, published in Transplantation and Cellular Therapy, revealed a troubling pattern of disparities in access to CAR T-cell therapy for patients with relapsed or refractory large B-cell lymphoma.The research, which analyzed data from over 5,000 eligible patients, found that factors such as age, race, and income significantly impact the likelihood of receiving this therapy. Surprisingly, proximity to a treatment center also played a crucial role, with patients living 2 to 4 hours away from the nearest CAR T-cell facility being nearly 40% less likely to receive the treatment compared to those living within 30 minutes."We mapped the distance, and it turned out that if you live 2 to 4 hours away from a transplant or therapy center, you are way less likely than if you live closer" to receive CAR T, Gergis said. The study also found that older patients, men, and Black patients were less likely to receive the therapy, further highlighting the need for a more equitable approach to care.

The Burden of Employer-Driven Restrictions

The issue of access to CAR T-cell therapy is not limited to patients on state Medicaid plans; it also affects those with private insurance and employer-sponsored health care plans. Many insurers and employers have implemented preferred treatment locations, known as Centers of Excellence (COEs), or other restrictions that dictate where patients can receive these therapies.As the cost of cancer care and the incidence of the disease continue to rise, employers are increasingly turning to these COE programs, which include bundled payments and warranties. According to a report by Carrum Health and PwC, the national incidence of cancer in people younger than 50 years is expected to rise 31% by 2030, with treatment spending reaching $246 billion – and employer-based insurance will be responsible for half of this cost.While these COE programs aim to provide patients with better care while reducing costs, they can also create additional barriers to accessing the most appropriate treatment. Walmart, for example, has a COE program that directs its employees with certain types of cancer to specific Mayo Clinic locations, potentially limiting their options and requiring them to travel long distances.

The Caregiver Burden and Patient Challenges

The stringent post-infusion monitoring requirements for CAR T-cell therapy, which mandate that patients remain near the treatment center for 4 weeks and refrain from driving for 8 weeks, add to the caregiver burden. This can be particularly challenging for patients with families, as they may need to relocate or make significant adjustments to their lives to receive the treatment.Sloane Cammock, CPNP, a clinical trials nurse navigator for the Leukemia & Lymphoma Society, described the difficult situation faced by one of her patients – a woman in her 40s with cancer who had to choose between relocating away from her family to receive CAR T-cell therapy or staying local and receiving a different, potentially less effective, treatment. The decision was complicated by the fact that her husband could not accompany her due to work and childcare responsibilities.In another case, an older patient was able to have his three adult children, who had children of their own, rotate their visits to care for him during and after the CAR T-cell treatment. However, not all patients have the same level of family support, and the burden can be especially challenging for those with young children or limited resources.

Exploring Potential Solutions: Reducing Monitoring Requirements and Expanding Access

While the distance to treatment centers poses significant challenges for patients seeking CAR T-cell therapy, recent research suggests that the stringent 4-week monitoring requirement may not be entirely necessary. A study published in Blood Advances found that among 475 patients who received various CAR T-cell therapies, not a single case of cytokine release syndrome occurred 2 weeks after infusion, and only one incident of new-onset immune effector cell–associated neurotoxicity syndrome appeared in the third week."A flexible monitoring period may help decrease financial and geographic limitations for patients and make CAR T more accessible and feasible," wrote lead author Nausheen Ahmed, MD, associate professor of hematologic malignancies and cellular therapeutics at the University of Kansas Cancer Center. "We propose reducing the monitoring period to 2 weeks, with the flexibility of extending monitoring to a total of 4 weeks, contingent on patient stability, physician comfort, and the availability of local community oncology support."Addressing the broader issue of access, Kolton Gustafson, MPH, principal of policy practice at Avalere Health, suggests that stakeholders explore ways to fill the gaps that prevent patients from receiving CAR T-cell therapy. This may include provider education, expansion of treatment sites to the community setting, and the development of patient assistance programs to address the financial and logistical barriers."This study helpfully shines a light on some of the other factors that can influence access to treatment beyond the patient's distance from a treatment site, including income and race," Gustafson wrote. "These are characteristics for which there are many documented disparities in care, but the application to CAR T could influence how stakeholders think about prescribing, referral pathways, patient assistance, and cost sharing for treatment."As the field of cancer care continues to evolve, it is crucial that we address the systemic barriers that prevent patients from accessing the most promising and transformative therapies. By working collaboratively to overcome these challenges, we can ensure that every individual, regardless of their geographic location or socioeconomic status, has the opportunity to benefit from the life-saving potential of CAR T-cell therapy.