Bridging Distance, Delivery Gaps in Cancer Care

The influx of novel therapies is expanding treatment options for patients with cancer, but distance, infrastructure, and payer hurdles still prevent patients from receiving optimal care, experts highlighted at the Institute for Value-Based Medicine^® event in Salt Lake City, Utah, that took place August 27, 2026.

Across 4 panel discussions, speakers stressed that closing these gaps will require more comprehensive up-front testing, stronger partnerships between academic centers and community practices, and care models that bring treatment closer to patients’ homes.

Closing Biomarker Testing Gaps in Lung Cancer

The event opened with “Precision in Practice: Implementing Biomarker Testing in Lung Cancer,” moderated by Shiven Patel, MD, MBA, associate professor, Division of Oncology, Utah School of Medicine and investigator, Huntsman Cancer Institute. The panel consisted of Justin A. Call, MD, of Utah Cancer Specialists, as well as Matthew Gumbleton, MD, PhD, and Courtney Cavalieri, PharmD, both from Huntsman Cancer Institute. They explored how tissue limitations, payer requirements, and geographic distance complicate biomarker-driven care in non–small cell lung cancer (NSCLC).

Patel noted that guidelines have expanded to include RNA testing and companion biomarkers for antibody-drug conjugates. Sequencing is “an absolute necessity,” he said, yet real-world completion rates still lag. Call said insufficient archival tissue is the most common reason that testing fails, whether because of suboptimal biopsy size or tissue exhaustion from immunohistochemical stains.

“One of the most…gut-wrenching feelings is when you have a patient with newly diagnosed metastatic lung cancer,” he said. “You’re waiting for the tissue [next-generation sequencing (NGS)]…and then that email comes in 2 weeks later: not enough tissue.”

Call added that in his experience, insurance and patient-cost barriers have largely disappeared. To work around tissue shortfalls, Gumbleton said he orders blood and tissue testing concurrently for every patient. If blood testing reveals a clear driver mutation, rebiopsy may not be needed; otherwise, his team rebiopsies.

The panelists agreed that spot testing has little role in NSCLC. Gumbleton said broad NGS preserves tissue and captures alterations, such as MTAP deletion, that are likely to become targetable soon. Call also supported broad, tissue-based NGS in early-stage disease.

Payer scrutiny adds another layer of complexity. Cavalieri said some payers have pushed back when only PD-L1 results were submitted, requesting definitive proof of EGFR or ALK negativity before approving therapy.

On managing the wait for results, Gumbleton noted that guidelines recommend, when possible, holding frontline therapy until molecular results are available. Still, he said a few cycles of chemotherapy may serve most patients well, even those later found to have an ALK or ROS1 alteration.

Each decision is individualized, Call said. He may start by treating symptomatic sites such as bone metastases while awaiting results. For very ill hospitalized patients, he may begin chemotherapy right away, especially because NGS often cannot be ordered until a patient has been discharged for some time. Patel said bridging measures such as radiation to painful sites helps reassure anxious patients because “the last thing they want to do is hurry up and wait.”

When a targetable alteration surfaces late, Call said most clinicians would switch to targeted therapy even if the patient is responding. Gumbleton said it depends on the mutation and the patient’s course. He described one patient on neoadjuvant chemoimmunotherapy whose EGFR L858R result arrived after cycle 2. The patient was progressing and responded after pivoting to the combination of amivantamab-vmjw (Rybrevant; Janssen Biotech, Inc) plus lazertinib (Lazcluze; Janssen Biotech, Inc).

The discussion then shifted to patient access, with Patel saying he uses telehealth to deliver results such as an ALK-positive finding to rural patients, sparing them a 10-hour drive each way. Cavalieri said Huntsman Cancer Institute’s specialty pharmacy is licensed in neighboring states, so pharmacists can counsel patients remotely and ship medications to their door when payers allow. Gumbleton noted that mobile phlebotomy for minimal residual disease testing reduces the time toxicity of cancer care. Call added that staff at his practice’s Idaho locations are dedicated to ordering and tracking molecular tests.

To improve clinical trial access, Cavalieri stressed arranging trial-required supportive care medications in advance, including refills through a local pharmacy. Gumbleton pointed to umbrella studies such as the phase 2 NAUTIKA1 trial (NCT04302025) to address the rarity of individual mutations.¹ He also suggested letting patients complete routine laboratory work, such as comprehensive metabolic panels (CMPs), locally.

“Driving 10 hours for a CMP is just…ridiculous,” Gumbleton said.

Call noted that more sponsors now budget for hotel vouchers, mileage reimbursement, and per-visit stipends of $75 to $100.

“There’s transportation, there’s gas money, there’s hotel stays, there’s food costs; these are indirect costs,” Call said. “It doesn’t cost anything to be in the trial, but for people in rural areas who are traveling, these indirect costs add up, and more and more studies now are including that in their budget.”

Navigating First-Relapse Decisions in Multiple Myeloma

The discussion then turned to hematologic cancers when moderator Amandeep Godara, MBBS, of Huntsman Cancer Institute, led “Scaling Innovation: Delivering Targeted Therapies, CAR-T, and Bispecifics in Multiple Myeloma.” He was joined by panelists Ghulam Rehman Mohyuddin, MBBS, and Kelley L. Julian, PharmD, both from Huntsman Cancer Institute, and Prashant Sharma, MD, of Intermountain Health. The panel examined how clinicians are choosing among an expanding set of therapies at first relapse and how access and toxicity shape those choices.

Mohyuddin said he generally favors B-cell maturation antigen (BCMA)–directed bispecific antibodies at first relapse but noted ciltacabtagene autoleucel (cilta-cel) (Carvykti; Janssen Biotech, Inc) risks such as parkinsonism and colitis. Still, he said cilta-cel is reasonable for patients who accept those risks, want a treatment holiday, and can travel to the treatment site for an extended period. Mohyuddin said he avoids talquetamab-tgvs (Talvey; Janssen Biotech, Inc) at first relapse, calling it “a tough drug to stomach, literally and metaphorically.” He also questioned where belantamab mafodotin-blmf (Blenrep; GlaxoSmithKline LLC) fits because it may reduce the efficacy of subsequent BCMA-targeted therapy.

Sharma, who recently lost a patient to cilta-cel–related hemophagocytic lymphohistiocytosis, said he generally leans toward BCMA bispecifics for older patients and chimeric antigen receptor (CAR) T-cell therapy for younger ones. Julian added that first-relapse decisions depend on physician and patient preference. She noted that idecabtagene vicleucel (Abecma; Bristol Myers Squibb) remains an option for select older or frailer patients, although it is less efficacious.

She also raised a concern that starting bispecifics in the community could push CAR T-cell therapy to the back burner. Mohyuddin rejected the notion that CAR T-cell therapy must come first and said he typically stops bispecific therapy after about a year. Godara added that fixed-duration treatment may preserve BCMA as a target for later therapy.

Panelists were cautious about cereblon E3 ligase modulators. Sharma cited neutropenia rates of nearly 50%.² Mohyuddin saw a limited role for them as a bridge to CAR T-cell therapy, whereas Godara noted that the time to response may not fit bridging needs.

Sharma emphasized that geography shapes treatment choices. For patients 8 to 10 hours away, he said a regimen such as carfilzomib (Kyprolis; Onyx Pharmaceuticals, Inc), pomalidomide (Pomalyst; Bristol Myers Squibb), and dexamethasone may make more sense than traveling for teclistamab-cqyv (Tecvayli; Janssen Biotech, Inc). Sharma also described expanding bispecific access beyond the Salt Lake Valley through hospital partnerships, emergency medication stocks, and clinician availability.

“If you’re comfortable with FOLFIRINOX [leucovorin calcium (folinic acid), fluorouracil, irinotecan hydrochloride, and oxaliplatin], what’s [the] big deal with teclistamab?” he said.

In addition, Julian highlighted a hub-and-spoke model with shared education and supportive care resources for community nurses, and Mohyuddin noted that prophylactic tocilizumab has made grade 2 or higher cytokine release syndrome almost nonexistent.

For bispecifics, Mohyuddin stressed infection prevention, including intravenous immunoglobulin (IVIG) and antimicrobial prophylaxis, and said treatment breaks may suit responders with recurrent infections. For CAR T-cell therapy, he urged vigilance for delayed neurotoxicity and colitis after patients return to community care.

Looking ahead, Sharma emphasized rural access and non-BCMA options as priorities, and Mohyuddin called for more comparative data to guide treatment decisions.

“We definitely need better head-to-head trials of these agents, and we should retire trials that have triplets as control arms,” Mohyuddin said.

Bringing Novel Therapies Closer to Home in Lymphoma

The event stayed in the hematology realm after a short networking break with “Developments in Drug Delivery in Leukemia and Lymphoma,” moderated by Daniel Ermann, MD, of Huntsman Cancer Institute. He was joined by panelists Harsh Shah, DO, of Huntsman Cancer Institute, and Robert Havard, MD, of Utah Cancer Specialists. Together, they examined how oral therapies, bispecific antibodies, and CAR T-cell therapy are reshaping care in chronic lymphocytic leukemia (CLL) and lymphoma.

The panel began with CLL, with Shah saying that Bruton tyrosine kinase (BTK) and BCL2 inhibitors have largely replaced chemotherapy, allowing clinicians to treat patients in their 80s and 90s. Havard said he has never used chemoimmunotherapy in CLL.

Because these oral therapies are taken at home, adherence is a focus. Havard said that early in treatment, a lymphocyte spike signals that patients are taking their medication, but he checks in more closely once they respond. He added that his clinic’s in-house pharmacy tracks refills. Ermann noted that some patients quietly halve doses or skip days. For patients with poor adherence during twice-daily dosing, Shah said he may choose once-daily BTK inhibitor zanubrutinib (Brukinsa; BeOne Medicines USA, Inc) over acalabrutinib (Calquence; AstraZeneca Pharmaceuticals LP).

Treatment is also moving closer to home in lymphoma as bispecific antibodies expand into community settings. Havard said a physician in his practice now performs outpatient bispecific ramp-ups, although he still refers many patients to Huntsman Cancer Institute or Intermountain Health and delivers maintenance in his clinic. Scaling the program across the practice’s 8 Salt Lake Valley locations, he said, will require infusion and triage nurses who can recognize and report complications.

Academic centers are moving in the same outpatient direction. Shah said Huntsman Cancer Institute no longer admits patients for the 48-mg epcoritamab-bysp (Epkinly; Genmab US, Inc) dose and has a 5-day rapid ramp-up for patients with high tumor burden. Ermann added that glofitamab-gxbm (Columvi; Genentech, Inc) is given outpatient with prophylactic dexamethasone. Havard said that wherever treatment takes place, infection prevention, including IVIG and antimicrobial prophylaxis, remains central to bispecific care.

Turning to CAR T-cell therapy, Havard said it has changed his surveillance practice in diffuse large B-cell lymphoma; he now orders earlier scans to catch nonresponse sooner, although guidelines have not changed. Referrals move quickly in Salt Lake City, Havard noted, and he decides on bridging therapy in consultation with the CAR T-cell therapy provider.

Shah agreed that the process has improved, with faster insurance authorization and more bridging options. However, he said patients from neighboring states such as Nevada still face delays that can cost them a collection window.

Insurance barriers extend well beyond CAR T-cell therapy, the panelists noted. Shah described a plan affiliated with The Church of Jesus Christ of Latter-day Saints that lacked FDA-approved bispecifics and loncastuximab tesirine-lpyl (Zynlonta; ADC Therapeutics SA) on its formulary, requiring outreach to the state. He also described a Medicare patient with T-cell lymphoma who had no prescription coverage and could receive only free drugs from manufacturers.

Anticipating similar problems, Havard said he urged a patient under CLL surveillance to add prescription coverage during open enrollment. When gaps do arise, he and Ermann said grant programs, manufacturer representatives, and samples serve as critical stopgaps.

Administrative tools offered more mixed results. The panelists welcomed electronic prescribing and artificial intelligence note tools such as Abridge. Havard, however, said his electronic medical record makes it hard to reconstruct a patient’s treatment history.

Looking ahead, Shah said he expects bispecifics to move into the frontline setting for many lymphomas, with CAR T-cell therapy retaining a second-line role. Havard credited partnerships with academic centers for his practice’s bispecific capabilities, and Ermann encouraged clinical trial enrollment, noting that trials can cover drug costs and lodging for rural patients.

“I think we’re in an amazing space,” Ermann said. “I really think we’re in the golden era right now, and I think things will just keep getting better.”

Addressing Rural Barriers to Cancer Care and Clinical Trials

The evening concluded with “Advancing Patient-Centered Oncology in Utah: Navigating Barriers to Care,” moderated by Kyle Kitchen, PharmD, of Utah Cancer Specialists. The panel included Christos Vaklavas, MD; Siwen Hu-Lieskovan, MD, PhD; and Jordan McPherson, PharmD, MS, all from Huntsman Cancer Institute. They examined the structural barriers rural patients face and how health systems can extend care and newer therapies beyond major centers.

The scale of the challenge is significant. Vaklavas noted that the region that Huntsman serves covers about 17% of the continental US and called for stronger collaboration with affiliate practices through hub-and-spoke models. McPherson emphasized that distance is only one barrier, citing missed work, transportation, and socioeconomic factors as others. Given these complexities, Hu-Lieskovan said that team-based care involving advanced practice clinicians, pharmacists, nurses, social workers, and local oncologists is essential for patients traveling from as far as Montana and Nevada.

Pharmacy teams are playing a central role in closing these gaps, McPherson said, pointing to Huntsman Cancer Institute’s medication access coordination technicians. They serve as a single point of contact across medical and pharmacy benefits and handle foundation and grant applications. The specialty team is also adopting software to automate form completion. Beyond the main campus, Huntsman Cancer Institute funds a pharmacist dedicated to its 7 regional affiliates, McPherson said. However, he acknowledged that standardizing educational materials across literacy levels, disabilities, and languages remains a work in progress.

For patients enrolled in clinical trials, these burdens are often magnified. Hu-Lieskovan described a patient traveling 10 hours for an early-phase trial with frequent pharmacokinetic draws, and she said Huntsman Cancer Institute asks sponsors to cover lodging and travel. Weighing those demands, Vaklavas said that as breast cancer lead, he deliberately avoided trials requiring heavy patient commitment, such as CAR T-cell studies.

Other efforts aim to bring trials to patients instead. McPherson said Huntsman Cancer Institute recently received federal funding for a mobile clinical trial vehicle serving 3 rural counties, although regulatory hurdles have slowed progress.

Echoing earlier panels, the discussion then turned to bispecific antibodies, for which the infrastructure demands are steep in community settings. Kitchen said only 1 of Utah Cancer Specialists’ 12 clinics performs step-up dosing, partly because round-the-clock support is difficult to provide. Vaklavas said these therapies require an ecosystem of pharmacists, emergency physicians, and hospitals familiar with their toxicities.

Solid tumor teams face an added hurdle. McPherson noted that prophylactic tocilizumab is not guideline supported or reliably reimbursed in solid tumors. Hu-Lieskovan said she admits patients for the first 3 doses of tebentafusp-tebn (Kimmtrak; Immunocore Limited) in uveal melanoma, but weekly dosing remains the larger obstacle.

“I refer patients to local oncologists to give it, and oftentimes they send patients back to me because they said, ‘I cannot give it,’” she explained.

As a potential solution, Hu-Lieskovan suggested home health could eventually manage cytokine release syndrome with clear protocols. Vaklavas was similarly optimistic, comparing bispecifics to the early days of ipilimumab (Yervoy; Bristol Myers Squibb) and predicting broader adoption as indications expand.

The panel closed by considering whether subcutaneous formulations could move more care into the home. So far, that shift has been slower than expected; McPherson said insurers have not required home administration. Site-of-care rules have instead pushed patients to ambulatory infusion suites, and current payment models offer no incentive for the shift. Kitchen noted that subcutaneous agents are also more expensive. Practical limitations also remain, as Hu-Lieskovan pointed out that subcutaneous nivolumab (Opdivo Qvantig; Bristol Myers Squibb) and pembrolizumab (Keytruda Qlex; Merck Sharp & Dohme LLC) still require infusion center visits and large injection volumes.

“It’s kind of interesting to see how this is all evolving, but [it’s] not as rapid of a shift as I thought it would be,” McPherson said.

References

1. A study of multiple therapies in biomarker-selected participants with resectable stages IB-III non-small cell lung cancer (NSCLC) (NAUTIKA1). ClinicalTrials.gov. Updated October 13, 2026. Accessed October 22, 2026. https://clinicaltrials.gov/study/NCT04302025
2. Lonial S, Popat R, Hulin C, et al. Iberdomide plus dexamethasone in heavily pretreated late-line relapsed or refractory multiple myeloma (CC-220-MM-001): a multicentre, multicohort, open-label, phase 1/2 trial. Lancet Haematol. 2022;9(11):e822-e832. doi:10.1016/S2352-3026(22)00290-3