Advancing the Integration of CAR T-Cell Therapy in Community Oncology Centers: Key Findings from a Transformative Quality Improvement Initiative
Authors: Nawaz M. Sarfraz , Moses-Okwei Ellie , Gurska Lindsay , Zyborowicz Emily , Sullivan Shelby , Carter Jeffrey , Heggen Cherilyn 
Published: December 2024

Background
Much progress has been made in the treatment of non-Hodgkin lymphoma (NHL); however, providers face challenges in navigating the complexity of chimeric antigen receptor (CAR) T-cell therapy. PRIME's prior initiatives identified barriers to timely referral and care coordination for NHL patients eligible for CAR T-cell therapy. To improve NHL care, we implemented a practice transformation model among community oncology providers to overcome barriers to optimal, patient-centered CAR T-cell therapy care.
Methods
This initiative included 56 provider baseline surveys, a network-wide audit-feedback (AF) session with community-based care teams, and 90-day follow-up surveys. The surveys evaluated practice patterns, challenges, and barriers to NHL care with CAR T-cell therapy. Care teams and a nationally renowned NHL physician specializing in CAR T-cell therapy participated in the AF session to assess practice gaps, prioritize areas for improvement, and develop action plans to address root causes.
Results
Demographics: The respondents included 20% hematologists/medical oncologists, 20% nurse practitioners or physician assistants, and 39% nurses, averaging 9 years of experience caring for NHL patients, with each provider managing approximately 10 diffuse large B-cell lymphoma (DLBCL), 7 follicular lymphoma (FL), and 6 mantle cell lymphoma (MCL) patients per month.
Surveys and A/F Sessions: Providers were split equally in their reports of moderate/low versus high/very high confidence in their ability to discuss the manufacturing and administration process of CAR T-cell therapy, differentiate CAR T-cell treatment options for NHL subtypes, and monitor and manage adverse/late effects. Top challenges in applying clinical evidence and guidelines to treatment plans include optimal sequencing (39%), staying current with emerging evidence (32%), and differentiating CAR T-cell therapies for NHL subtypes (32%). Additionally, 46% reported moderate/low confidence in identifying NHL patients eligible for CAR T-cell with main barriers of sequencing after prior therapy (25%) and rapid disease progression (23%). A small proportion of providers (DLBCL (11%), FL (5%), and MCL (9%)) reported always referring eligible patients for CAR T-cell therapy. Common barriers to referral included difficulty in collaborating and communicating with CAR T-cell centers (39%), identifying eligible patients (34%), and obtaining timely referrals (34%). Collaboration and communication levels between CAR T-cell centers and oncology clinics were rated fair/poor (24%), good (25%), and very good/excellent (51%); providers noted that paired education between clinics and CAR T-cell centers on treatment administration and care coordination (48%) and guidelines on patient referral and insurance approval (38%) would be most helpful. Care teams' action plans to improve NHL CAR T-cell therapy included: enhancing efforts to identify and refer patients; increasing staff knowledge on CAR T-cell treatment; increasing communication across care teams; educating patients on treatment options, including CAR T-cell therapy; and developing checklists for better care coordination with CAR T-cell centers. Follow-up surveys (n = 10) showed 100% reported improvements in identifying and referring NHL patients for CAR T-cell therapy and aligning clinical practices with guidelines. The greatest progress was noted in designing evidence-based workflows for patient management and communication with CAR T-cell centers. However, persisting challenges were reported in therapy selection, insurance approval, and timely referrals.
Conclusions
Healthcare providers disclosed significant barriers that limit optimal CAR T-cell therapy care for NHL. Key challenges included identifying eligible patients, collaborating with CAR T-cell centers, managing adverse events, and staying updated with clinical data. Targeted intervention in these areas is crucial to optimizing CAR T-cell therapy for NHL. These insights can guide future initiatives to bridge gaps in community settings in quality care for NHL patients.
Study Sponsor Statement
The study reported in this abstract was funded by an educational grant from Novartis Pharmaceuticals, who had no role in the study design, execution, analysis, or reporting.