Clinical Perspectives R/R LBCL: Eligibility, Treatment Selection, and Barriers to CAR T Therapy

CAR T-cell therapy, while a transformative option for R/R LBCL, involves more than clinical eligibility—it demands a comprehensive, multidisciplinary, and patient-centered approach. Candidates are typically assessed for adequate cardiac, pulmonary, hepatic, and renal function, though perfection isn't required. Unlike stem cell transplantation, CAR T-cell therapy can often be safely administered to patients with comorbidities, with modifications to the conditioning regimen. The key is early involvement of specialists to ensure safety, particularly in patients with borderline organ function or complex medical histories.

Operational and logistical factors also play a major role in treatment planning. Patients must remain near the treatment center—typically for at least 2 weeks—and have a 24-hour caregiver. Though recent changes to regulatory requirements have relaxed some of these expectations, the need for local accommodation, reliable transportation, and round-the-clock support remains. These logistical requirements often present significant challenges, especially for individuals who are caregivers themselves, live far from treatment centers, or lack robust social support systems.

Financial and social barriers are often the most difficult to overcome. Even when insurance covers the therapy, the out-of-pocket costs related to travel, housing, food, and caregiving can be prohibitive. Patients must also manage personal responsibilities at home, including care for children, older parents, or pets. Centers often involve social workers early in the process to identify gaps and connect patients with grants or assistance programs. Education and psychological support are also essential, as patients and families must navigate a complex process under emotional strain. Tools such as educational websites and support from advocacy groups can help empower patients to make informed decisions and advocate for themselves during treatment planning.