Community Providers Face Hurdles With CAR T-Cell Therapy Referrals and In-Office Infusion

Few community practices are performing in-office infusions on CAR T-cell therapy, but due to interest from 20% of them, experts recommend stakeholder alignment to address the concerns of the oncology population.

According to hematologists/oncologists, the current referral processes at tertiary sites have made it challenging to refer patients for chimeric antigen receptor (CAR) T-cell therapy. Other challenges identified with the referral process may also limit future outpatient CAR T-cell administration, according to the physicians surveyed.

The community physicians were a part of a cross-sectional survey conducted by Cardinal Health Specialty Solutions with the overarching goal of understanding how physicians perceive barriers to in-office CAR T-cell infusion and the factors that physicians consider when deciding to refer patients to undergo CAR T-cell therapy at a tertiary site.

CAR T-cell therapy is a new and innovative treatment approach that has been FDA approved in multiple hematologic malignancies, and because of its importance in treatment for hematologic malignancies, the surveyors though it important to gather data from the physician population. Further, there is a known disparity around the availability of CAR T-cell therapy in rural vs suburban settings that has not been well described in prior research.

“This is observational research, which Cardinal has had more than a decade experience conducting. Some of that research actually does require physicians abstracting charts of patients. In some cases, it's combining that charge abstraction with understanding physician perceptions and physicians’ experiences. And so, we're able to not only know and look at the sequence of events, but we're also able to address the why behind those choices and those sequence of events. So, the work that we do is often trying to get physicians to give us that firsthand account. What was the patient experience? What led you to make this choice in treatment? What were the potential barriers to exercising that choice of treatment? What were the patient outcomes from that choice?” explained Bruce Feinberg, DO, vice president, chief medical officer Cardinal Health Specialty Solutions, in an interview with Targeted Oncology™. “Often, we don't get that full story because when we're looking at only the clinical trials, we really see just that episode of care around the treatment itself, we see what happened at that institution when the CAR T cells were administered, not the story that led up to it or the story that follows when those patients returned to the community.”

Characteristics of the physician population showed that 22.1% were from large, privately owned community practices, 13.2% were from small, privately owned community practices a, 5.9% were from medium, privately owned, community practices, and 1.5% were from solo, privately owned, community practices.The population also included physicians from academic centers or affiliated teaching hospitals (32.4%), community-based hospitals (7.4%), and medical centers or cancer centers (2.9%).

In terms of primary medical specialty, the majority of the physicians who responded to the survey were hematologists (64.7%), with the rest being either medical oncologists (33.8%), or other (1.5%). The mean years in practice among the survey responders was 9.7 years (range 2-43).

According to the survey results, most physicians (39%) referred 2 to 5 patients to a certified CAR T-cell treatment center to receive commercially available and FDA-approved CAR T cells in the past 3 years. Notably, 27% of physicians did not refer any patients to received CAR T-cell therapy, 20% referred 1 patient, 4% referred 6 to 10 patients, another 4% referred 11 to 15 patients, and 6% referred greater than 15 patients.

Physicians have 9 options for which type of CAR T-cell treatment center they are most likely to refer patients to and why. The top 4 responses showed that center reputation and location were the key factors.

Other factors, such as quick responses from the referral center, a CAR T-cell therapy supported by more published research, recommendations from colleagues, knowledge of CAR T-cell therapy, and patient eligibility, were less impactful on the physicians’ decision making.

In terms of the second survey goal, physicians have 5 options of CAR T-cell administration setting they utilize. Forty-seven percent of responders said their practice does not administer CAR T-cell therapy, 25% administer them at the hospital and have no intention on performing in-office infusions, 20% administer in the hospital but are considered in-office infusion, 6% perform in-office CAR T-cell therapy infusions, and 2% do both hospital and in-office infusions.

The top barriers to performing in-office CAR T-cell therapy administration were the ability to manage acute/immediate complications of treatment (78%), concerns around in-patient hospitalization within 2 hours after CAR T-cell infusion (66%), as well as lack of knowledge of the infusion process or CAR T cells, challenges with billing and reimbursement, and prior authorization/payer approval (38% each).

“The barriers that we have witnessed are those barriers we've seen before. [The barriers are] having an educated community workforce of healthcare providers who are knowledgeable about these treatments, an academic, tertiary care environment, where they remove all the barriers to those patient referrals, and hopefully patients who understand to some degree that complexity of the program, so that they will be willing to undergo consent for those procedures. Each of those barriers exist, but each of those barriers has been seen before, and we can really rely on past experiences to help guide us forward,” said Feinberg.

Because few practices are performing in-office CAR T-cell administration and there is a growing interest in doing so, Feinberg et al recommend stakeholder alignment to address the concerns of the oncology population.


Pink S, Deune-Smith Y, Klink AJ, et al. Community hematologist/oncologist (CH/O) barriers to CAR T referral and concerns with possible in-office car-t administration. Presented at: 2022 International Society for Pharmacoeconomics and Outcomes Research; May 15-18, 2022. Washington, DC. Abstract HSD44.