Ensuring Access to CAR T Cells Among Rural Multiple Myeloma Populations

Joshua Richter, MD, spoke with Marco Davila, MD, PhD, about addressing gaps in care for patients with multiple myeloma who live in rural settings or lack caregivers who can relocate with them to treatment centers for access to CAR T-cell therapies. According to Davila, various support programs can aid with transportation and lodging, thereby addressing some of the logistical barriers surrounding treatment. They also emphasized determining individual patient preferences, which can help elucidate candidates for outpatient care.

Davila is physician–scientist and service chief of the Lymphoma–Myeloma Adoptive Cell Therapy Service at Roswell Park Comprehensive Cancer Center. Richter is associate professor of medicine at the Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, and director of Myeloma at the Blavatnik Family Chelsea Medical Center at Mount Sinai.

Transcript:

Richter: I was worried it was going to come to this kind of upstate–downstate back-and-forth between the 2 of us. I'm glad I get to ask this next question: for patients in a rural area or without a caregiver who can relocate for weeks, what can be done to improve access to novel cellular therapies?

Davila: Yeah, "rural" is a bit more adept to upstate New York because I'm not sure if Queens counts as rural. But absolutely, this is an important problem. If you look at a map of New York, and you look at treatment centers, CAR T treatment centers, upstate New York is kind of a desert. There are only 2 main treatment centers in upstate New York: it's us and Rochester. There [are] a lot of people who live in upstate New York, but they would live in an identified rural area. To me, it's really important.

We're funded in part by the state; we're a New York public benefit corporation. We consider ourselves to be New York's cancer center. No offense, but we have to solve these types of problems. For me, when you're talking about rural patients, it's about access to the expertise, access to transportation, and caregiver coordination. Every patient and every practice is going to be a little different, but we try to figure out, what are the big problems that occur again? Sometimes, it's the distance back and forth. As I've said, we're able to collect patients closer to their homes, and that reduces some of these barriers. It's not for all products, but we're trying to set it up so it is available for all products.

Also, [there is] telemedicine. [We are] seeing some of these initial visits, at least being able to get plugged into our system, get the authorization process going, and relying on telemedicine. The shared-care model [involves] holding therapy, bridging therapy being able to happen in the patient's home, not necessarily in downtown Buffalo. [It’s about] being able to get the patient back home as quickly as possible and share their long-term surveillance with the primary medical oncologist. These are all things that we've done to address this and get this information out to patients and referrers because we don't want them to think that the barriers that existed there 5 years ago are still there today. We're trying to solve these problems, and as we solve one, we just move another one up the list. Luckily, most of these standard-of-care products include very generous support programs for the patients that can help with things like transportation and lodging. There are resources available to the patients, and we're trying to use them all and develop our own.

Richter: I couldn't agree more. Access here is key. And one of the things that you bring up is that the needs of one group are going to be different than others. There are many patients at your center and mine where the patients are screaming that they want it all outpatient. They don't want to be admitted to the hospital. But you may have someone who's a little older, maybe a little farther away. They may be the patient that we admit to the hospital for the whole thing just to make sure that during those critical points, we don't have to worry about the patient having a toxicity and going to a local emergency room that may have no experience with how to manage acute-onset toxicities of cellular therapy.

Davila: Yeah, absolutely. In wintertime, it snows every once in a while in Buffalo, and having an 85-year-old person having to drive through a snowstorm is not the [best]; I want to be able to go to heaven one day. I'm very happy to say, “Hey, let's not do the outpatient thing. Let's admit you to the hospital to manage this.” It's just to highlight that yes, there are lots of problems, but we can solve those problems if we discuss them as a team.