From CAR T-Cell Therapy to ADCs: Tackling Oncology Access Gaps

From prior authorization delays to the logistics of frequent infusion visits, persistent access barriers are shaping how community and academic oncologists sequence emerging therapies, even as the treatment landscape expands. Panelists at the Washington, DC, Institute for Value-Based Medicine^® on June 25, 2026, described how insurance hurdles, social determinants of health, and toxicity management are increasingly dictating the timing of chimeric antigen receptor (CAR) T-cell therapy and bispecific antibodies, while similar cost and scheduling challenges complicate the rollout of antibody-drug conjugates (ADCs). The discussions underscored a common theme: As options multiply, care delivery and access—not just clinical efficacy—are becoming the deciding factors in patient outcomes.

Scaling Innovation: Delivering Targeted Therapies, CAR T, and Bispecifics in Multiple Myeloma

Moderator Kashif Ali, MD, an oncologist at Maryland Oncology Hematology (MOH), led this discussion, engaging panelists on the influence of T-cell fitness and prior therapies on CAR T-cell therapy effectiveness. The timing, when done correctly, can provide patients with a break in treatment until their next round of therapy, according to panelist Jennifer Kanakry, MD, medical director of the Stem Cell Transplant and Cellular Immunotherapy Program at MedStar Georgetown University Hospital. Many patients still don’t receive CAR T-cell therapy until late in their treatment course, but there is a minority of patients who do receive it early, she explained.

“Maybe they’ve advocated for themselves or have good insurance, and if you break down some of those nonmedical barriers to self-therapy in the DC area, I feel like we still see several lines of therapy,” Kanakry said. Her statement helped the conversation pivot to a broader theme of treatment access. Clinicians often face barriers when scaling or translating newer therapies because patient access relies heavily on social determinants of health and the presence of caregiver support, Ali said.

“How are you deciding on [which] treatment for these patients, or how are you helping [guide] your patients’ journey and making sure that they actually have access to these quick treatments?” he asked the panelists, underscoring the disproportionate access rates among minority communities.

In response, Mohit Narang, MD, chair of pharmacy and therapeutics at MOH, noted that outpatient settings have had ample practice in delivering bispecifics and helping patients manage toxicities, multidisciplinary communication, and long-term follow-up. “When we have opened the studies for outpatient-based bispecifics, we had a few more patients with that,” he said.

But the process of getting these therapies to patients can still be quite lengthy. Laura Yarbro, PharmD, a clinical pharmacy services manager at MOH, explained that prior authorizations and insurance approval are significant barriers for certain patient populations, citing MOH as an example.

“I think the one issue that we look at is, at least for our practice, the matter of their insurance and what they’ll cover; usually that’s the first step,” she said. “Then the next step is determining the affordability.”

In contrast, delivering tailored treatment regimens is increasing in multiple myeloma care as new therapies are becoming available, giving patients and providers more options to choose from. Selecting therapies from a growing pool helps providers address patients’ needs outside of the target disease.

“Many of these bispecifics, when you give them for a long time, we are seeing much more frequent infections,” Narang said in an interview with The American Journal of Managed Care^® (AJMC^®). “[At the] end of the day, I believe the quality of life matters the most. I think that should be a bigger end point, and that should be looked at in the real-world studies.”

Despite the continued growth of treatment options, Ali asked the panelists how they manage gaps in care, especially for patients entering later lines of treatment, waiting for CAR T-cell therapy.

Narang responded by exemplifying courses of treatment he’s enacted in the past. For patients with multiple myeloma, he initiates transplant/cellular therapy at the time of diagnosis. For patients with lymphoma, he prefers to start transplant/cellular therapy after patients complete their course of treatment to prevent the risk of relapse, which is higher in those patients, he said.

Similarly, Kanakry explained that she and her care team plan patients’ course of treatment before they reach later-line treatments.

“It’s counts not the time it takes to collect and manufacture, but then what we’ve decided to do for bridging that dictates when the patient will go to CAR [T-cell therapy],” she said. “I have a whole list of patients whose CARs are ready, but we’ve now dictated this timeline, or maybe they have some complication, and it needs to be optimized more before that.”

Ali ended the panel discussion on the topic of minimal residual disease (MRD) as a new end point for multiple myeloma clinical trials and how community and academic practices manage those outcomes, as they are not currently in the National Comprehensive Cancer Network Clinical Practice Guidelines for Multiple Myeloma.

“If someone is MRD negative and they become MRD positive at small values, we don’t really know yet what [to] do with those patients. Do we increase the treatment and put them on something else?” he asked. “If MRD negative, do you take them off treatment?”

Narang answered Ali’s question by addressing the growing number of therapies that have been approved based on MRD. In contrast, Kanakry said she refers patients back to their community oncologist to monitor and ultimately make the final decision.

Targeted Success: Operationalizing Therapies in Breast Cancer

Despite numerous therapies and new therapies, like ADCs and CDK inhibitors, within the breast cancer space, clinicians face challenges in operationalizing these therapies across a diverse health care setting.

Moderator Jennifer Bires, MSW, LCSW, OSW-C, executive director of integrative and psychosocial oncology at Inova Schar Cancer (Inova Schar), began the conversation by asking panelists how these therapies reshaped their clinical approach to treating HER2-low and HER2-ultralow disease. Jennifer Sheng, MD, assistant professor of oncology at Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, expressed her enthusiasm for the numerous FDA approvals of ADCs but noted that the delivery of said therapies depends on an institution’s or practice’s patient population and resources.

“As we look at all these drugs that are getting approved…I think cost is just one piece of it,” she said. “It’s also logistics. It’s how frequently someone has to come in when they’re coming in twice a week the first week, twice a week the second week, potentially, and then another week, because oftentimes these patients are needing additional support.”

In addition to managing cost and logistical barriers associated with the growing treatment landscape, toxicities are another hurdle clinicians have to navigate.

“ADCs have unique [adverse] effects that we haven’t seen with our traditional chemotherapy…. It’s really hard to figure out how closely you need to follow what the trials did for checking CTs or [pulmonary function tests] and who needs these and for how long,” said panelist Melissa Yacur, MD, medical oncologist specializing in hematology at Inova Schar.

Bires urged the panelists to identify any workflow or operation barriers when implementing newer therapies. Yacur also explained that data for newer therapies outpace the FDA approval process, requiring her to often prepare requests for medical necessity for insurance companies the moment the drugs become available. She’s been able to accomplish as much because of her efficient team of financial representatives.

Sheng capitalized on Yacur’s emphasis on internal team support, communication, and coordination to expedite prior authorization and insurance approvals that would help patients access their care sooner rather than later.

“I think division of labor is really important. I’ve been pleasantly surprised by how quickly you can actually get some of these approvals,” Sheng said. “I think the takeaway is that it’s a huge labor of love to really get this quickly through for patients, that we get it.”

Bires broadened the conversation to address another theme of access disparities: how they present in patients with breast cancer and affect access to associated therapies.

“Disparities are certainly something that we commonly see mentioned in clinical trials, but really in access to treatment. I’d like to hear from you all,” Bires said. “How are you seeing access disparities show up in the patient populations we’re treating right now?”

Rebecca Kaltman, MD, a breast medical oncologist at Inova Saville Cancer Screening and Prevention Center, explained how some initiatives at her institution deliver care to patients in the community. In doing this, they can reach more patients who otherwise wouldn’t be able to access an academic or community oncology center.

“We have just launched, in the past 9 months or so, a mobile unit, and we don’t just do mammography. We actually do every type of cancer screening. We also enroll in clinical trials,” Kaltman said. “I think it’s important that we’re not just waiting for patients to come to us at stage III and sometimes stage IV disease, as we know can happen in certain communities. We’re really going out to reach them there.”

The financial and structural support to bridge patient access disparities are a benefit of larger practices. However, Sheng explained that smaller practices take more personal routes or strategies to address these barriers, such as getting Ubers for patients so they can get to a center to receive care, but also, more importantly, utilizing existing resources.

“We don’t need to reinvent the wheel, and there are numerous nonprofit organizations that offer free or very low-cost services across the country,” Sheng said in an interview with AJMC.

Other internal resources such as translators, nurse practitioners, and nurse navigators are tools that both small and large health institutions and practices can implement to further address and bridge this massive access disparity gap, Sheng said.

Using Sheng’s statement as a segue in multidisciplinary care, Bires asked panelists how they utilize their care teams to effectively manage patients’ treatment cycles and adverse events and shepherd them into survivorship care.

Having large care teams benefits patients, primary care providers, and the next generation of oncologists, Yacur said, underscoring the importance of passing down operationalized workflows and implementing new treatments into clinical practice workflows that streamline patient care and improve outcomes.

“We want to make sure that our fellows are exposed to all of these subspecialties within oncology, like cardio-oncology or pulmonary oncology, so that when they go out and practice in the community where they may have fewer resources, they can actually do a lot of the basics that these specialists are doing for their patients without necessarily having to refer them,” Yacur said.

Bires concluded the conversation by looking ahead to survivorship care and how clinicians and community oncology centers continue to meet patient needs.

“When I came to Seville, a lot of the thought was, ‘What is survivorship?’” Kaltman said. “We really look at is as a continuum.”

Innovations in Lung Cancer Treatment: Targeted Therapies, Bispecifics, Etc

Collaboration between care teams and administrations is key to implementing new targeted therapies and immunotherapy strategies in lung cancer care. Panelists discussed the operational and clinical considerations to integrating targeted therapies and bispecifics into practice.

Moderator Aliyah Pabani, MD, MPH, assistant professor of oncology and codirector of the immune-related toxicity team at Johns Hopkins Medicine (JHM), started the conversation by asking the panelists to explain the biggest changes in their practice that transformed how they approach lung cancer care. The panelists agreed that new targeted therapies have improved outcomes for patients, allowing them to live longer, but that they also come with their own set of adverse effects and management considerations.

Vincent Lam, MD, a thoracic oncologist at JHM, said that it feels good to tell patients with severe or late-stage lung cancer that there are successful and efficacious therapies to help them better their quality of life living with their condition. “We’ve made more progress in lung cancer in the past 3 to 5 years than the previous 3 decades combined, and that’s generally due to 2 main things: immunotherapy and continued personalization of lung cancer therapy,” he said. “I think it’s really all of the above reasons a lot of us really enjoy the lung cancer space, because we get access to these rapid developments across multiple treatment modalities.”

But despite the prospect of these therapies for patient outcomes, operational barriers remain a challenge, especially among infusion centers, pharmacy workflows, and education monitoring programs. In response to Pabani’s question on how they overcome these challenges, Stefanie Houseknecht, PharmD, BCOP, clinical pharmacy specialist in ambulatory thoracic malignancies at Johns Hopkins Bayview Medical Center, cited that toxicities and adding immunotherapy to treatment plans are significantly more difficult because of cost.

“You’re trying to justify why we need to add this additional drug that’s potentially going to have 5 months of progression-free survival, and it’s going to come with all of these extra toxicities,” Houseknecht said. “I think that’s a challenge: convincing our health system of the value of this and then also, on the payer side of things, to get patients access to it.”

Building on Houseknecht’s point about cost hindering care, Lam highlighted that subcutaneous immune-oncology same-day lab work puts a strain on clinical workflows that haven’t adapted as of yet. The workflows are designed to affirm any immune toxicities in patients’ labs the day prior to receipt of care, he emphasized.

“I think that seems to put a tremendous strain on our workflow to actually do these late binding decisions that immunotherapy uniquely brings, as opposed to chemotherapy, for instance, which is a lot more predictable,” Lam said.

Clinicians also face a prior authorization barrier based on payer preferences, Houseknecht added, leaving the audience with this question: “How do we implement the adoption of subcutaneous immunotherapy when actually the payer is going to have a much louder voice in the equation than I think we want them to? And how are we going to navigate that without causing delays in patient access?”

In contrast, panelist Susan Scott, MD, assistant professor of oncology at JHM, said that subcutaneous immunotherapy may not be as beneficial to patients compared with other subcutaneous formulations of other immunotherapies.

“It doesn’t have the safety component that we’ve seen for other subcutaneous formulations,” she said. “It doesn’t really obviate the need for an infusion center visit until they're requiring us to give it at home.”

Next, Pabani asked the panelists how they manage toxicities when implementing new workflows, integrating new therapies, and, more specifically, combination therapies.

“We used to think about toxicity management in separate buckets,” she said. “Your chemotherapies, your targeted therapies, your immunotherapies. But as we’re using more combination therapy [and] sequential therapy, do we need to rethink how we organize toxicity management?”

The 3 panelists agreed that combination therapies are frequently administered in conjunction with immunotherapies, but their main concern is making sure patients are educated on their treatment plan to accurately report any symptoms.

Pabani concluded the discussion with a final question focused on biomarker testing in addition to different targeted therapy options: How has it influenced clinicians’ workflows?

“It’s a huge challenge to get these results in a timely fashion, and we work so hard to come up with new strategies, new working groups, and new initiatives,” Scott said. “It really does help if you can identify what kind of cancer they have before we have to start treatment, and that really does depend on getting a molecular result.”

Advancing Pharmacy Operations and Workflows in Oncology

For the final panel discussion, moderator Andre D. Harvin, PharmD, MBA, MS, chief pharmacy officer at the University of Maryland Medical System, addressed the evolving role of pharmacists over the past decade as they’ve integrated into clinical practices to better patient outcomes and broaden care access.

“How would you describe the role of oncology pharmacy today, and how has it changed in your career? Maybe especially within the past few years, have you seen this rise in complexity and opportunities within drug management?” he asked.

Clinical pharmacists now have multiple active roles in clinical practice and are becoming more involved in inpatient care teams and, in many cases, leading and tailoring patients’ treatment plans.

“Our pharmacist’s role is to ensure that all those things [are] there from the very beginning,” panelist Minhee Kang, PharmD, BCOP, BCPS, manager of oncology and research pharmacy at MedStar Georgetown University Hospital, said in an interview with AJMC. “The proper premedication and supportive care, like after nausea and vomiting, those kinds of things. We have to ensure that it’s there already.”

In comparison, in a community setting, pharmacists are more involved in clinical research and the revenue cycle, in addition to drug delivery and patient counseling, explained Jody Agena, PharmD, MBA, director of pharmacy operations at Virginia Cancer Specialists.

“[We are] way more involved with the clinical research side of things and the revenue cycle, [and] not only patient counseling but nursing education,” he said. “[We are] way more involved with the financial aspects of the practice. I think the oncology pharmacist is not really a clinical pharmacist anymore. They’re [in a more] well-rounded type of role.”

Yet, when translating care from an academic to a community setting, Agena noted that there is often a learning curve for pharmacists’ cost barriers, such as insurance authorizations and budgeting.

“The role is definitely expanded…you’re not only dispensing drugs and consultations anymore. There’s a lot more involved with the financial aspect as well,” he said.

Harvin then steered the conversation to focus on specialty pharmacy and the unique challenges that accompany clinical pharmacists filling roles traditionally managed by retail pharmacy operations.

“A thing that’s branched out of the specialty pharmacy…is we have these ‘rev cycle pharmacists’ we call them. We have a team of 3 pharmacists dedicated to this, where their main focus is to understand the margins and work with our rev cycle people in the…different oncology sites and try to understand what’s needed from a clinical perspective to produce different therapies,” said Ray Lake, MS, director of corporate pharmacy operations at MedStar Health.

Oncology pharmacists are now central to tackling financial toxicity and ensuring that cutting‑edge therapies are deliverable. Pharmacists are expected not only to manage drugs clinically but also to aggressively apply formulary and dosing policies, minimize waste, and align product selection with payer contracts—all with the goal of protecting patients from unaffordable costs while sustaining the health system.

“It’s not only just making a drug and preparing and verifying dispensing it, but also the revenue integrity [in a] pharmacist. We are really working on this money piece. It’s really talking to the insurance company,” Kang said, as the conversation pivoted to building structurally efficient pharmacy teams. “I know that a lot of clinical pharmacists are really involved in the prior authorization process.”

Beyond internal levers, the panelists stressed the importance of external partnerships and infrastructure for financial support, such as active outreach to manufacturers to understand patient assistance and free‑drug programs, as well as the use of third‑party vendors that automatically scan for philanthropic grants and match eligible patients. These initiatives allow the care team to walk into early treatment conversations already armed with concrete financial solutions rather than waiting until patients break down under the cost burden.

“Access and affordability are really some of the foundations when we think about clinical outcomes,” Harvin said, highlighting that even the best therapies fail if patients can’t afford to start or continue them.

The discussion concluded on the topic of integrating CAR T-cell therapy and bispecific T-cell engager therapy operations programs into community and academic practices.

“Our experience has been pretty not great as far as what we thought was the kind of support we were going to get from our pharma partners with the CAR T. And not only just the CAR T, but the hotel stay and the transportation. I think the pharma partners could do a better job as far as helping out the patients,” Agena said.

The panelists agreed with Agena’s statement, further emphasizing that pharmacists must advocate simultaneously to close the gap between recommended oncology care and what patients actually receive. Oncology pharmacy roles are evolving into hybrid, integrative positions that blend clinical expertise, operational leadership, and financial stewardship. The sustainability and equity of modern oncology care, the panel concluded, will increasingly depend on how effectively pharmacy teams can operate at all of these levels at once.