Bringing Advanced Cancer Therapies to Rural Communities: Hope Krebill, MSW, BSN, RN

As novel treatments such as chimeric antigen receptor T-cell (CAR T) therapy, bispecific antibodies, and circulating tumor DNA (ctDNA) testing reshape cancer care, ensuring access for rural and under-resourced communities remains a major concern.

In an interview with The American Journal of Managed Care^® (AJMC^®), Hope Krebill, MSW, BSN, RN, executive director of the Masonic Cancer Alliance at the University of Kansas Medical Center, describes the logistical and staffing barriers that limit access to these therapies outside of academic centers.

From the need for patients to relocate during CAR T therapy to the lack of specialized staff for managing bispecific-related adverse events, Krebill notes that infrastructure gaps continue to pose challenges. She emphasizes that sustained investment could support rural hospitals in building partnerships, offering virtual cancer care, and expanding infusion capacity to meet patient needs.

This transcript was lightly edited for clarity.

AJMC: Advanced therapies like CAR T and bispecifics, and tools like ctDNA, are reshaping cancer care. What unique challenges and opportunities do they create for rural or under-resourced communities?

Krebill: Bispecifics and CAR T can be a super big challenge for community sites, as well as for patients who live many hours from the CAR T center.

When a patient is enrolled on a CAR T study, or when they are receiving CAR T therapy, they have to stay in town for 30 days, for 4 weeks, and they have to have someone who can care for them. That's not so hard for me because I live in Kansas City, and I could just go back home to my house and my husband would be there. But if it was for my mother, who lives in a rural area, the whole family would have to move up and be in town for an extended time. She's retired, so that works for her, but what if they both worked? So, really trying to work through some of those concerns, being close to where the therapy is, and staying in town long enough.

Now, when we start looking at bispecifics, it has a whole other area of concern. I just recently visited multiple hospitals in Kansas and Missouri, and they are just starting to think about bispecifics and beginning that treatment. Some aren't even doing it yet. It really has to do with whether they have the specialists available if there are adverse events. Are they ready? Do they have a pulmonologist? A neurologist? Have the nursing staff on the floor taken chemo classes? You have to have a whole additional team that's available to not only recognize but then treat what could happen.

Not all of those community cancer centers with their hospital partners have yet felt that infrastructure to be able to support it. Many are working through it, and they're figuring out some really great ways to work through it. They still have the challenge. If you're the oncologist and there are 2 oncologists on your team, who's answering those late-night texts and calls from the nursing staff when they start seeing some problems? Some have really thought about, “Well, when do we start therapy, because I don't want to get those calls on the weekend.” There are some ways to approach it, but when the team is thinner, it's just more challenging to care for the patients.

Other hospitals have worked through it by having the therapy initiated outside of their community and then having the patients return. There are lots of solutions, but they will be a challenge, and they will place additional stress on a patient who is having social determinants of health issues, because that's going to be more costly if they have to go away for their treatment as well as if they have to be away from work. That still will be a challenge for them. I think in the next few years, we're going to see a whole tsunami of great therapies that come out, but really, we're going to start looking at who really has access to them.

AJMC: How could investments such as the proposed $50 billion Rural Health Transformation Program improve the infrastructure of rural hospitals?

Krebill: We're looking at really unique ways, like the Masonic Cancer Alliance. We started out in 2008 with the idea that we wanted to extend clinical trials to rural hospitals as well as underresourced hospitals in our metropolitan area. We also knew we wanted to be able to extend the clinical trials and that the local hospitals would not be able to fully engage in clinical trials if we didn't support the regulatory [or] the training of the staff. But what the hospital said was, “What we need are people to provide virtual second opinions to us.” We started using virtual second opinions in 2008, so way before the pandemic.

The hospital also explained, “What we need is professional education for our team. What we need is a relationship with the University of Kansas Cancer Center, and we don't really have that yet.”

Fast forward, we're now looking at models where there are ways to provide virtual cancer care at rural hospitals, and some of these hospitals, who now hopefully will stay open, will be able to both partner with the university and provide cancer care.

There's a hospital in Colby, Kansas, an hour from the state line for Colorado, so it's 5 to 6 hours from Kansas City, and it is this amazing, progressive community that cares about their cancer care. They don't have oncologists there, so how do you create that relationship? Well, they're building a $130 million hospital, and they have the foresight to create an infusion area so that they can partner with a variety of oncologists to provide care.

That $50 billion transformation grant, I'd ask them, how is that keeping your doors open? Because they're still with hard hats. They'll be opening their hospital in probably 2026, but hopefully that will keep their doors open. And when we talk Kansas, a lot of people won't know what Kansas is like. Seventy-five percent of our counties are rural; the majority of those counties have less than 6 people per square mile if you divide it up. It is a rural community, but people still need the care, and we need to figure out how to get them the care. Hopefully that will help.