Barriers to receiving CAR T-cell treatment among patients with non-Hodgkin lymphoma who were deemed eligible for CAR T-cell therapy

Abstract

Abstract Background: Advances in non-Hodgkin lymphoma (NHL) treatment options, such as chimeric antigen receptor T-cell therapies (CAR T) and bispecific antibodies, have improved outcomes for patients with relapsed/refractory disease. However, some patients referred for CAR T do not proceed with treatment, often due to patient fitness, disease progression, logistical challenges, or patient or physician preference, which is linked to worse patient outcomes. This study aimed to understand factors influencing physician decision to refer patients for CAR T and why some referred patients do not proceed. Methods: This study was based on syndicated surveys of oncohematologists in France (FR), Germany (DE), Italy (IT), Spain (SP), and the United Kingdom (UK) using data from IQVIA CAR T-Cell Monitor reports from Q2 and Q4 of 2023 and 2024. A total of 308 oncohematologists participated in IQVIA CAR T-Cell Monitor survey (2023–2024). Referring physicians reported on referral decisions, while CAR T center physicians provided insights on patient eligibility and barriers to treatment. Results are presented as percentages of physician responses to the survey questions. Results: Multiple factors affected physicians decisions to refer patients to CAR T treatment facilities. Overall patient health (Eastern Cooperative Oncology Group performance status [ECOG PS]/patient fitness) emerged as a significant barrier to referral across all countries (overall, 72% [DE, 78%; FR, 77%; IT, 73%; SP, 66%; UK, 61%]). Additional patient characteristics impacting referrals included comorbidities (overall, 82% [range 78%–87%]), ECOG PS (overall, 81% [78%–84%]), cancer stage/severity (overall, 55% [SP, 67%; IT, 60%; FR, 57%; DE, 44%; UK, 33%]), and age (overall, 52% [FR, 65%; IT, 58%; SP, 49%; DE, 46%; UK, 37%]). Side-effect profile was cited as a key barrier by 41% of physicians. Patient preference was a major driver for referral in the UK (65%), with lower influence in DE (58%), SP (44%), FR (45%), and IT (45%). Family support/logistics were more impactful in IT (57%), SP (43%), DE (38%), the UK (28%), and least in FR (18%). The interval between referral and treatment initiation was reported as a barrier by 56% of physicians (DE, 62%; SP, 59%; IT, 55%; UK, 55%; FR, 49%), while slot availability was significant for 41% (FR, 52%; IT, 52%; DE, 43%; UK, 36%; SP, 20%). Financial considerations related to health insurance posed a barrier for 28% (FR, 35%; DE, 32%; SP, 29%; IT, 24%; UK, 16%). Administrative burden, such as paperwork, was noted as a barrier particularly in SP (43%) compared with other countries (IT, 22%; DE, 20%; FR, 15%; UK, 11%). Patients referred for CAR T often did not proceed to treatment, primarily due to disease progression (SP, 81%; FR, 80%; UK, 80%; DE, 70%; IT, 68%) and eligibility/fitness issues (DE, 76%; UK, 70%; IT, 63%; SP, 62%; FR, 58%). Patient choice based on clinical or side-effect concerns contributed to non-initiation (overall, 31% [UK, 52%; DE, 46%; SP, 23%; FR, 23%; IT, 19%]). The availability of bispecific antibodies as an alternative treatment option was notable in FR (30%) and DE (24%) but lower in SP (20%), IT (18%), and the UK (15%). Logistical and administrative considerations heavily influenced patient choice in the UK (54%) compared with lower rates elsewhere (range 6% [SP] to 26% [DE]). Safety concerns were predominantly highlighted in the UK (31%). Conclusions: Although CAR T treatment has shown strong efficacy, this multi-country analysis highlights an unmet need for other treatment options among patients with NHL who were considered eligible for CAR T treatment. Patient characteristics continue to be a major differentiator in eligibility, and a considerable amount of time is lost among those initially deemed eligible. Referring centers cite patient characteristics (comorbidities, ECOG PS), patient preference, cost, side-effect profile, and CAR T availability as major barriers to referrals, while CAR T center physicians have similar concerns related to disease progression, patient eligibility/fitness, safety, and slot availability. These findings underscore the importance of identifying alternative therapies for these patients prior to referral.