Barriers to CAR-T Therapy Adoption: Comparing Access in Academic and Community Settings in the US

Background: Since the approval of the first chimeric antigen receptor (CAR) T-cell therapy in 2017, CAR-Ts have become increasingly important to treating cancer. Six CAR-Ts are now approved for various hematologic malignancies. However, despite the success of these innovative therapies, there are several factors that impede their widespread adoption. This study aimed to identify key barriers to CAR-T therapy consideration and administration and key differences between community and academic settings.

Methodology: Analysis of second-line plus (2L+) US patients who were indicated for CAR-T therapy based on their cancer type and line of treatment (CAR-T eligible) and evaluated for potential CAR-T therapy use from March 2022 to March 2024 was conducted. Data on patient consideration for CAR-T therapy, status with regards to therapy and barriers to receiving therapy was collected. The patient sample between April 2021 to March 2022 included 493 and 163 from community and academic settings, respectively. The latest 12 months of data, April 2023 to March 2024, included 1363 from community and 672 from academic settings. The physician sample by setting was 100 community and 38 academic from April 2021 to March 2022 and 376 community and 193 academic from April 2023 to March 2024. All reporting physicians were required to treat a minimum of 5 cancer patients per month with anti-cancer drug therapy and be the main drug decision maker for their patients.

Results: Taking into account new and expanded indications for CAR-T therapy, the proportion of CART-eligible patients reported to be considered for CAR-T therapy increased over the two-year period, particularly in the academic setting. Consideration rate in the academic setting rose from 25% in April 2021-March 2022 to 55% in April 2023-March 2024 (p<0.01). Within the community setting the rate showed a similar level of increase (18% to 43%; p<0.01) when comparing the same time . Both settings showed a large increase in CAR-T consideration for eligible patients, although consideration level is higher in academic settings.

The overall proportion of physicians whose primary practice can administer CAR- therapy has also risen over the past two years, particularly in community settings; 29% April 2021-March 2022 to 47% April 2023-March 2024 (p<0.01). Comparatively, the proportion of academic doctors whose facilities are able to administer CAR-T therapy was, and remains, much higher (82% April 2021-March 2022 to 88% April 2023-March 2024).

Even with the capability to administer CAR-T, barriers remain preventing some patients from receiving the treatment, particularly in community settings. Among patients approved for CAR-T between April 2023 and March 2024, a subset was unable to receive the treatment (6% in academic vs 9% in community setting). In the community setting, financial burden (33% vs 17%; p<0.01) and patient refusal (45% vs 28%) were more common barriers as compared to the academic setting. Logistical challenges (52% vs 21%; p<0.05) was the predominant barrier for patients treated in academic centers, while deteriorating patient condition was a minor barrier in both settings (14% academic, 16% community).

When evaluating patients not considered for CAR-T between April 2023 and March 2024, clinical ineligibility (due to ECOG, comorbidities, etc.; 43% vs 31%; p<0.01) and safety concerns (27% vs 7%; p<0.01) were more commonly cited as barriers for patients treated in academic centers. Contrastingly, physician preference for conventional treatments (32% vs 16%; p<0.01) was the primary barrier for patients treated in community practices. In both settings, patient refusal was a notable barrier (36% academic, 31% ).

Conclusions: This study highlights significant disparities in CAR-T therapy consideration and administration between academic and community settings for US 2L+ CAR-T eligible patients. Inability to administer CAR-T is a barrier in the community setting, although travel to a capable facility may present other logistical (academic setting) and financial (community setting) challenges. Consideration for CAR-T therapy in the community setting, while increasing, is still hampered by community doctor preference for conventional treatments. By understanding the factors that hinder CAR-T therapy administration in community settings, healthcare providers can help ensure that more patients benefit from CAR-Ts.