Bringing CAR T-Cell Therapies to Community Oncology Practices

Expanding the delivery of chimeric antigen receptor (CAR) T-cell therapies in community settings is a critical step toward improving access to novel cancer treatments for all patients, particularly as indications expand for use in pediatric and adult oncology.

Implementation is admittedly complicated, given the additional workforce and infrastructure requirements for advanced cellular therapy compared with traditional therapies such as chemotherapy and radiation.

But it is doable, safely and effectively, and the potential benefit to patients with relapsed or refractory blood cancers is already immense.

Our practice, Virginia Oncology Associates (VOA), has provided in-office CAR T-cell therapy to nearly 60 patients over the past 2 years. Most of them have diffuse large B-cell lymphoma or multiple myeloma. We have also treated patients with relapsed chronic lymphocytic leukemia, mantle cell lymphoma, and acute lymphoblastic leukemia.

In April 2024, VOA became the first standalone community practice to infuse idecabtagene vicleucel (Abecma) in a patient with multiple myeloma in the community setting. In August 2025, VOA also became the first community practice site to treat a patient with a second multiple myeloma CAR T-cell therapy, ciltacabtagene autoleucel (Carvykti).

Both patients remained out of the hospital for the duration of their treatment and are doing well to date. For all our patients treated with CAR T-cell therapies, the hospital admission rate has been approximately 30%, meaning a remarkable 70% have avoided an inpatient stay.

Like many community-based practices, VOA is not located near the type of large academic or cancer center that has historically offered advanced immunotherapy, typically as part of a hematopoietic cell transplantation program.

In the past, our patients would have to travel more than 100 miles away to access such a facility and spend a month away from their families, homes, and jobs. Understandably, that often is impossible, especially for people with lower incomes.

In fact, of the patients we have treated with in-office CAR T-cell therapy to date, we estimate that half would not have been able or willing to travel so far outside our service area. Therefore, they likely would not have received a potentially lifesaving treatment or, at minimum, delayed it until they had reached a more advanced disease state.

By staying close to home, patients and their caregivers can avoid travel and lodging costs, minimize lost work wages, and reduce the physical and emotional stress of separation from loved ones, familiar environments, and established medical teams.

To be sure, establishing a safe, effective community-based CAR T-cell program takes significant planning and effort. Logistical and financial hurdles have caused many practices to shy away from tackling the challenge.

The process first requires building a strong, multidisciplinary team of physicians, nurses, pharmacists, and support staff on-site, all of whom need to be well-trained in working with patients treated with CAR T-cell therapy and their caregivers.

Duties range from ongoing patient education to recognizing potentially dangerous toxicities in the weeks after an infusion, such as cytokine release syndrome, immune effector cell–associated neurotoxicity syndrome (ICANS), low blood cell counts, and allergic reactions.

Symptoms that necessitate immediate attention include fever, chills, muscle aches, fatigue, and low blood pressure and/or oxygen levels. ICANS also can lead to confusion, tremors, difficulty speaking or writing, and, without intervention, seizures and coma.

Before we ever treated a patient in the outpatient setting with CAR T-cell therapy, our team met regularly to build the CAR T-cell program, using local hospital leaders, national pharmaceutical companies, the Foundation for the Accreditation of Cellular Therapy, and organizations such as the Red Cross to establish partnerships, protocols, and communication channels.

Other steps included as follows:

Creating a dedicated infusion space for CAR T-cell (and stem cell) therapies. This infrastructure is crucial for managing toxicities and maintaining strict infection control; the latter is particularly important for patients with cytopenia following conditioning chemotherapy.

Our infusion area is equipped with medications approved to treat CAR T-cell therapy complications. The separate space also helps us maintain strict guidelines for storing, preparing, and delivering personalized cellular products as well as for meeting numerous regulations and providing a quiet and private setting for patients.

Establishing a partnership with a nearby hospital. Our hospital partner is Sentara Norfolk General Hospital in Virginia, a level I trauma center located 6.5 miles from our infusion center. The relationship with the hospital is vital to safely treat patients who receive a CAR T-cell therapy.

Routine education and training sessions with hospital staff, including emergency departments and intensive care units, are critical to remaining ready to treat patients who need to be admitted to the hospital for toxicity management.

Securing permission from drug companies and insurance payers. Although CAR T-cell therapy has FDA approval, some commercial payers still do not recognize the ability of community practices to deliver these therapies locally.

Therefore, we need more education about programs such as the one at VOA to demonstrate the value of improved access to care for patients as well as cost savings to payers by keeping patients out of hospitals.

Setting clear patient guidelines. Patients need 24/7 caregiver coverage for support and monitoring after treatment. We ask them to stay within a 30-minute drive of our CAR T-cell infusion center at the Sentara Brock Cancer Center in Norfolk for a period of 14 to 28 days. Fortunately, most of our patients live within that distance.

Patients receive daily checkups for 7 days post infusion; they also receive prophylactic treatment with antibiotics. Follow-up appointments are scheduled as needed at the physician’s discretion. Many patients require monthly visits for the first year.

The time for community-based centers to evaluate the need for providing advanced cellular therapies as an outpatient option—and to begin formulating a plan to attack obstacles and barriers—is now.

Soon, CAR T-cell therapy is expected to expand beyond blood cancers to treat a range of solid tumors, including breast cancer, lung cancer, prostate cancer, gastrointestinal cancers, glioblastoma, melanoma, head and neck cancers, cervical cancer, and sarcoma.

Additionally, the therapy has shown promise in clinical trials for common autoimmune diseases such as lupus, rheumatoid arthritis, type 1 diabetes, inflammatory myositis, and systemic sclerosis.

Social determinants of health should not influence what patients do or do not do to have a chance to receive therapies that could extend their lives. Community-based oncologists can and should take action to address this significant access-to-care issue.

Gary Simmons, DO, MSHA, is a medical oncologist at Virginia Oncology Associates in Norfolk.