Barriers to CAR-T Therapy Utilization Among Community Hematologists/Oncologists in the US

Ajeet Gajra, MD, FACS, SUNY Upstate Medical University, Jamesville, NY, discusses findings from a study analyzing the utilization of and barriers to CAR-T therapies by community hematologists/oncologists in the United States, discussing deterrents such as cost and lack of support.

These findings were presented at the 2021 ASH Annual Meeting.

Transcript: 

My name is Ajeet Gajra, and I serve as the Chief Medical Officer at Cardinal Health Specialty Solutions. I want to talk about our study, "Barriers to Referral for Chimeric Antigen Receptor T-Cell Therapies Among US Community Hematologists/Oncologists," which was just presented at ASH 2021.

CAR-T therapies have been approved since 2017. As we saw at ASH 2021, there is renewed interest with the latest results presented ASH that is ZUMA-7 and also the TRANSFORM study. In this context, it's even more important to assess how CAR-T therapies are being perceived, viewed, utilized, or not utilized by community-based hematology/oncology practices.

We all know that CAR-T centers are largely large centers or academic centers. We wanted to assess if community-based oncologists and the patients treated there have easy access to CAR T-cell therapies at these larger approved CAR-T centers or what the barriers might be. That was the rationale, or the background, for conducting a study.

We enrolled almost 400, so 371 oncologists from across the US and asked them about their CAR-T therapy use, their referral patterns, and barriers experienced. This was conducted via a compensated online survey between January and April 2021, so close at the heels of ASH 2020.

We asked them if they had referred a patient for CAR T-cell therapy since their first approval in 2017. Almost three-fourths had. That's 72%. Half of them, that's 53%, had actually referred a patient for CAR T-cell therapy in the preceding 6 months.

Notably, the vast majority of the patients who were referred by them for CAR T-cell therapy in the preceding 6 months did receive the CAR T-cell therapy infusion, so over 84% of them actually received the treatment that they were referred for.

We then did a deeper dive into what were some of the challenges that the community oncologists perceived in terms of referral and utilization of CAR-T, and a few things bubbled to the top. One was, of course, a slow approval process by payers, which was identified as a barrier by almost a third. Other, potentially modifiable, problem was slow intake process at the CAR-T center.

Of course, this may be limited by capacity but may be expanded by greater accommodation of more centers and also expanding cellular therapy capacity at CAR-T centers because the community oncologists earlier identifying that as a barrier. Notably, a third, so 30%, said that they were no barriers at all. That is, I think, very positive news.

Other issues that we tried to assess, that the oncologists might have encountered in patients' CAR-T journeys, were that almost 40% said that patient deteriorated before CAR-T product could be administered, which is not surprising. Unfortunately, these patients are ill. Again, appropriate use of bridging therapy could temporize that difficult period.

Again, 20% said they encountered no challenges. Notably, a very small minority, 10%, said that the CAR T-cell product could not be manufactured, and another 11% cited lack of communication from CAR-T center during the process.

Based on this, I feel as though the manufacturing process has vastly improved, and the speed at which the product is turned around has obviously markedly improved. Of course, there's always room for better communication between physician groups and practices, so the academic center and the community practice. There's always room for that.

We assessed their view on cost. Notably, over half felt that the cost, even though they may be high, are not inappropriate based on the efficacy data for these therapies. That is quite a shift compared to early days when cost was thought to be prohibitive.

Almost 60% of the docs said that costs are really reasonable for this breakthrough therapy, and only 3% said that costs are too high and that will prevent them from referring their patients for this therapy.

Amongst other barriers aside from cost, which still is considered a barrier but becoming more acceptable, certainly, logistics of administering and following patients is cumbersome, and concerns for toxicity still remain a possible concern.

What can be done by all stakeholders, by pharmaceutical manufacturers, by CAR-T centers, and by professional societies in terms of promoting access to and appropriate utilization of CAR-T cell therapies for the right patients?

These community-based oncologists would certainly appreciate more financial aid and reimbursement support for their patients. This goes beyond insurance. Trips to a larger center can involve transportation, overnight stays, and also some invisible costs, which may not be easily reimbursable or visible to the insurance company, let's say.

These physicians are also asking for more education for themselves. 53% of them cited need for more education and 29% requested more education for patients. Then again, 37% requested better coordination and communication between physicians and sites of care.

In terms of additional data, more long-term real-world data was thought to be needed. We certainly are seeing that come along. Smoother and more timely approval process by payers was, again, requested by 33%.

In conclusion, we felt that most community-based hematologists/oncologists are now utilizing CAR-T, or referring patients for CAR-T, and their patients are appropriately receiving CAR-T cell therapy. There seems to be greater acceptance for the cost of CAR T-cell therapy within the majority of those surveyed.

The logistics of CAR T-cell therapy are still a significant barrier to referral, but community oncologists would really welcome additional resources to aid their CAR-T utilization.

We certainly hope that, even though this is a descriptive survey, that this information from the community front lines can help stakeholders streamline some of the logistics and perhaps develop better payment and support models so that this novel therapy can find access to greater number of patients. Thank you. 

Gajra A, Jeune-Smith Y, Feinberg B. Barriers to Referral for Chimeric Antigen Receptor T Cell (CAR-T) Therapies Among U.S. Community Hematologists/Oncologists (cH/O). Presented at the ASH Annual Meeting and Exposition; December 11-14, 2021; Atlanta, GA and Virtual. Abstract 4010.