The potential impact of chimeric antigen receptor T-cell (CAR-T) therapies should not be underestimated, nor should their complexity. There is much to consider when reprogramming patients’ own immune cells. As most cancer patients are seen in the community setting, community oncologists will play an instrumental role in patient referral and likely determine the initial adoption of this treatment. A broader understanding of stakeholder knowledge and perception of these new treatments may be critical to their adoption and use. It may be helpful to consider the history of care coordination and integration as it evolved in hematopoietic cell transplantation (HCT) centers. These facilities rose to the challenge, as cancer facilities will need to do in the near future.
In his opinion piece “The CAR-T Breakthrough: More Than Just Another Treatment Option,” Dr Wong raises valid concerns regarding newly approved CAR-T therapies, including associated side effects, costs, and challenges they pose to the current system of patient coordination and integration of services within episodes of care. Barriers to adoption are both numerous and complex, as we previously outlined in our recent paper, “Community Oncologists’ Perception and Adaptability to Emerging Chimeric Antigen T-Cell Therapy.” In this piece, we posited that understanding oncology providers’ perceptions of CAR-T efficacy, toxicity, and relative cost to value is essential to drive strategies for market uptake.1 To begin to understand their perceptions and opinions, we conducted surveys of physicians attending regional conferences with questions related to these topics. Recognizing barriers provides an opportunity for healthy debates on how best to develop strategies to overcome them.
We agree that payers will always play a major role in patient access for any new entrant to market, but harmonized collaboration between payers and other stakeholders will hopefully mature to help patients in need of CAR-T therapies. Proof of the impediments to rapid deployment of CAR-T technology is the less-than-robust market uptake since Food and Drug Administration approval as well as the increasingly long queues of patients pending evaluation and treatment.2
Apropos to the expression “necessity is the mother of invention,” the potential lifesaving nature of CAR-T therapies and the observed responses in highly refractory patients may serve to expedite practical solutions to improve access for eligible patients. This was the case for bone marrow transplant in hematologic malignancies 2 decades ago: regional referral centers, bundles services and payments, shared risk pricing scenarios, provider-to-provider communication and patient handoffs, and comprehensive clinical guidelines normalized what was initially a too complex, too costly, and too risky treatment alternative.
Earlier this year, an article3 was written showing how care delivery at HCT centers could serve as a model for complex patients, as many of the structures needed for an effective medical home model already exist in the HCT setting. According to authors, “HCT centers have developed integrated care delivery teams that oversee the care of the patient over an extended period of time covering both inpatient and ambulatory settings. The HCT field has developed organizational structures that facilitate standardized care where possible and that emphasize quality management practices that encourage the evolution of increasingly effective efficient practices.”3 These facilities rose to these care challenges out of necessity, reorganizing care coordination and integration of services, but this did not occur overnight.
We are but months since the first CAR-T approval and suggest cautious optimism for solving the complexities around this novel therapeutic drug class/procedure. Our article1 mentioned above provides a more comprehensive look at what payers, providers, and patients need to collaborate on at an early stage to adapt the therapies into the market place.
1. Nabhan C, Jeune-Smith Y, Klinefelter P, Fillman J, Feinberg BA. Community Oncologists’ Perception and Adaptability to Emerging Chimeric Antigen T-Cell Therapy. J Clin Pathways. 2017;3(8):31-35.
2. Cortez M, Chen C, Rausch N. Months after approval, breakthrough cancer drug given to just five patients. Bloomberg News. https://www.bloomberg.com/news/articles/2017-12-14/cancer-patients-with-little-time-left-wait-for-gilead-s-new-drug. Updated December 14, 2017. Accessed April 2, 2018.
3. Gajewski JL, McClellan MB, Majhail NS, et al. Payment and care for hematopoietic cell transplantation patients: toward a specialized medical home for complex care patients. Biol Blood Marrow Transplant. 2018;24(1):4-12.