The United States has some of the best healthcare in the world—but not for everyone. This is especially true for cancer patients who need complicated care like hematopoietic stem cell transplantation (HCT) or immunotherapies such as CAR T cell therapy. Both are very complex to administer, have long durations of treatment and require logistical coordination far beyond just making it to the hospital for appointments.
“When HCT or CAR T is the right next step for a patient, the last thing we want is for them to be unable to get that treatment,” says Dr. Hannah Abrams, a Hematology-Oncology Fellow in the Clinical Research Division. Unfortunately, many patients struggle to receive care for nonmedical reasons, or “because they can't meet a logistical requirement, like being able to obtain local housing or find a caregiver,” Dr. Abrams explains.
These nonmedical barriers to care are complex, which makes them challenging to study and address. Furthermore, national reporting of nonmedical barriers to care is not standardized between cancer institutions. For instance, many only look at data for who doesn’t get treated after referral, missing people who needed treatment but didn’t get referred. Other data sets don’t document logistical challenges that make up nonmedical barriers.
To address some of these knowledge gaps, Dr. Abrams and her colleagues in Halpern Group in the Clinical Research Division conducted a comprehensive assessment of barriers to HCT and CAR T care at large academic cancer centers in the United States. Their results were recently published in Transplant Cell Therapy.
“The goal of our study was to survey transplant centers nationally to find the 'best practices'” that balance safety of the transplant and cell therapy procedures with logistical support,” says Dr. Abrams. “It is the first national survey of its kind to delve so deeply into the details of some of these logistical requirements.”
The National Comprehensive Cancer Center Network is a network of 33 nonprofit, NCI-designated academic cancer centers. Each has a best practice committee that filled out the survey. The survey had questions “regarding center volume, eligibility assessment, caregiver/housing requirements, available modifications to therapy (such as telehealth use or inpatient admission), contraindications and policies for assessment, consent process, and staffing.”
One major observation was a large disparity in how centers interact with the caregivers needed for support treatment, largely compromised of unpaid family and friends of the patient. Much of the caregiving requirement depends on the treatment: CAR T only requires a month of caregiving while HCT requires up to four months. However, the requirements or allowances for caregivers varied greatly from institution to institution. Many centers required caregivers for outpatient care–some at 24/7 availability—for over 100 days. Most at least allowed the caregiver assignment to rotate between multiple individuals. While some institutions supported the cost for paid caregivers, others banned paid workers entirely. If caregivers were not available, some hospitals got “creative” by admitting people to the hospital for the duration of their care.
The majority of centers required patients to find local housing, meaning somewhere to stay no more than 120 minutes away from the center; others required a max time of 30 to 60 minutes to reach the hospital. This is a challenge because most centers in the National Comprehensive Cancer Center Network are located in densely populated, expensive cities. Although some centers allowed telehealth appointments for follow-up, this was not a standard practice.
Living situation was not just an issue for long distance patients: homelessness was considered an exclusion criterion for both HCT and CAR T therapy in about half of the centers that reported their exclusion criteria. Other exclusion criteria were lack of insurance (in over half of the centers surveyed), substance use, or medication non-adherence.
The survey had space for each center to rank what the providers felt the most common barriers to treatment were. For autologous HCT, allogeneic HCT, and CAR T, the top three barriers were 1) caregiver availability, 2) finding local housing, and 3) insurance or out-of-pocket costs.
“What we found is that there are several areas - like the distance patients are required to stay near the center or policies on substance use - where there's not a clear national standard or where some centers may be able to adjust their requirements to make it easier for patients to access treatment,” says Dr. Halpern.
These findings are especially important as many centers prioritize outpatient treatment over inpatient admission. Outpatient treatment has lower hospital costs and is likely preferred by patients for comfort purposes, but there are hidden logistical costs. “While all-outpatient therapy offers great promise, our findings suggest that patient and caregivers’ logistical efforts are a major and potentially under-recognized component of efforts to safely shift therapy to the outpatient setting,” the authors conclude.
This study clearly identified several logistical hurdles in patients’ ability to get needed care and illustrates a lack of national standards among cancer centers that may be hampering patients.
“We hope that centers around the US will be able to use these results to evaluate where their policies fall relative to the rest of the country and reassess any logistical requirements which may be more stringent than others',” says Dr. Halpern.
Fred Hutch/University of Washington/Seattle Children’s Cancer Consortium Members Mary-Elizabeth Percival, Roland Walter, Jacob Appelbaum, Mohamed Sorror, and Anna Halpern contributed to this research.
The spotlighted research was funded by the Fred Hutch/University of Washington/Seattle Children's Cancer Consortium.
Abrams HR, Starks H, Bandini L, Harrington T, Percival MM, Walter RB, Russell K, Mawad R, Appelbaum J, Sorror ML, Halpern AB. 2025. National Landscape of Logistical and Nonmedical Requirements for Transplantation and Cellular Therapy. Transplant Cell Ther. doi: 10.1016/j.jtct.2025.10.031
Hannah Lewis is a postdoctoral research fellow with Jim Boonyaratanakornkit’s group in the Vaccine and Infectious Disease Division (VIDD). She is developing screens to find rare B cells that produce protective antibodies against human herpesviruses. She obtained her PhD in molecular and cellular biology from the University of Washington.
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