No Outcome Without Access: Delivering on the Promise of Cancer Care Equity

Advancements in oncology diagnostics and treatment are emerging faster than the health care system and stakeholders can adapt to them, while persistent inequities in access continue to shape outcomes. Clinicians, researchers, and policy experts discussed these perspectives during a recent Institute for Value-Based Medicine event in St Louis, Missouri, presented by The American Journal of Managed Care.

Across conversations on precision oncology, malignant hematology, cellular therapies, and social determinants of health (SDOH), the recurring theme was that innovation cannot achieve its potential without payer alignment, investment in infrastructure, and focused attention to equity.

“No outcome without access,” said Hope Krebill, MSW, BSN, RN, underscoring the meeting’s core message. Krebill is the senior executive director of the Masonic Cancer Alliance at The University of Kansas Cancer Center.

Precision Oncology in the Real World
The integration of genomic profiling, circulating tumor DNA (ctDNA), and minimal residual disease (MRD) testing is reshaping cancer care across tumor types, especially as they are implemented more in early stages and not just metastatic cases. In breast, gastrointestinal, and gynecologic oncology, these tools not only guide therapy selection but also inform sequencing, monitor response, and anticipate resistance.

For example, patients who have rectal cancer with mismatch repair deficiency are increasingly treated with neoadjuvant immunotherapy as the standard of care, based on data from the phase 2 NICHE-2 trial (NCT03026140).¹ In the study, 109 of the 111 patients who were treated with neoadjuvant nivolumab (Opdivo; Bristol Myers Squibb) plus ipilimumab (Yervoy; Bristol Myers Squibb) had a pathological response, 105 had a major pathological response, and 75 had a pathological complete response, with no recurrence over 26 months.

In breast cancer, ctDNA has become routine for monitoring progression and making treatment decisions, whereas molecular profiling in gynecologic malignancies guides targeted therapy use and reprofiling at recurrence.

Regarding treating patients with breast cancer, “I don’t think we can attend any of our clinics nowadays without thinking about ordering ctDNA or next generation sequencing for any of our patients,” said Faisal Fa’ak, MD, oncologist at WashU Medicine Siteman Cancer Center in St Louis. In metastatic breast cancer, he explained, ctDNA testing is primarily used in estrogen receptor–positive disease to guide sequencing decisions beyond the first line of therapy, but it’s difficult to capture disease heterogeneity once it has progressed after multiple lines of treatment. In early-stage disease, Fa’ak said, mRNA assays are used as prognostic tools to estimate relapse risk, but without interventional trial data, oncologists have not yet changed treatment recommendations.

However, barriers remain. Payer coverage for repeat molecular testing is inconsistent, particularly in early-stage disease, where its role is still evolving. However, speakers said internal repeat genomic profiling can cut costs to minimize reimbursement challenges. Infrastructure adds another layer; test results must be integrated into electronic health records (EHRs) in a way that informs treatment pathways, according to panelists, yet many systems lack this functionality. Clinicians emphasized that payer policies should support broader EHR integration and sustainable reimbursement for repeat testing.

“Institutions should invest in robust infrastructure,” said Olivia Aranha, MD, PhD, medical oncologist at WashU Medicine. “Collaboration and education of the key players involved in patient treatment is key, and equitable payout structure…you can make this available to everyone, not just a select few, and embrace a core plan that everyone agrees on. If you do all of that, you can really push this new innovative precision medicine to the next level and improve patient outcomes.”

Barriers in Blood Cancers: Diagnosis, Trials, and MRD
The stakes are especially high in malignant hematology. Delays in diagnosis and referral can directly affect survival, and slow payer approval for advanced therapies hinders timely treatment. In acute leukemia, experts said next-generation sequencing is now integral to stratification and trial eligibility. However, sendout testing at community sites often delays results, forcing treatment decisions without complete molecular data. In multiple myeloma, payer approvals for chimeric antigen receptor (CAR) T-cell therapy can stretch past 2 months, creating dangerous gaps for patients with aggressive disease.

Clinical trial participation highlights another layer of inequity. Patients in rural or resource-limited areas face challenges traveling to academic centers. Although industry-sponsored trials may cover transportation and lodging, investigator-initiated trials rarely do. Even when resources exist, literacy and mistrust are barriers, the panelists noted. Consent forms written at a graduate level exclude many patients who read below that threshold.

“There are very long conversations that involve a lot of paperwork, and for patients, sometimes those are written far above their understanding level, not because they are not intelligent but because they did not go past eighth or ninth grade,” said Emily Podany, MD, MPHS, an assistant professor of medicine and breast oncologist at WashU Medicine Siteman Cancer Center.

MRD testing is increasingly used in hematologic cancers, particularly to refine risk stratification in acute leukemia. Data show that patients with intermediate-risk disease who clear mutations after induction or consolidation therapy achieve survival outcomes similar to those of favorable-risk patients and may not need a transplant. However, MRD-positive patients benefit most from it, according to Zachary Crees, MD, assistant clinical director of the Center for Gene and Cellular Immunotherapy, Washington University School of Medicine. This real-time use of MRD is also being explored alongside novel therapies, such as bispecific antibodies, to improve outcomes.

Equity and SDOH in Cancer Care
The discussions also spotlighted the role of SDOH in determining who benefits from these advancements in cancer care. Food insecurity, transportation barriers, and job instability emerged as persistent challenges in the St Louis area, with a clinic screening effort revealing 30% of patients with breast cancer reported food insecurity within the first week of diagnosis. Providers emphasized that no treatment plan, however advanced, can succeed if patients cannot meet basic needs.

“How can you focus on taking anastrozole when you’re also trying to feed your kids?” Podany asked the audience. “You can’t, that’s just impossible. It’s an unimaginable situation.”

Missed appointments due to transportation were another major concern. Patients fear disclosing financial stress, worrying it may limit their treatment options, and social workers and navigators play a critical role in bridging these gaps, the speakers noted.

Clinical trial enrollment also depends on addressing SDOH. Transportation and lodging support, health literacy resources, and decentralized models were cited as essential; without them, trial participation will remain skewed toward patients with financial and geographic privilege.

CAR T and Bispecifics: The Cost and Capacity Crunch

Demand for CAR T-cell therapy far outweighs delivery. According to Armin Ghobadi, MD, professor of medicine and clinical director of the Center for Gene and Cellular Immunotherapy, Washington University School of Medicine, an estimated 20,000 to 25,000 patients in the US qualify for CAR T each year, but fewer than 4000 actually receive it.² Distance from treatment centers, caregiver requirements, and payer approval delays are just some of the barriers, he said.

Reimbursement models exacerbate the problem. Current Medicare rules allow full payment only if CAR T is administered in an outpatient setting and the patient remains outpatient for 3 days post infusion. If hospitalization occurs within 72 hours, reimbursement drops below the cost of the product. Hospitals can lose $150,000 to $250,000 per patient, forcing many to cap the number of CAR T infusions they offer, Ghobadi explained.

Outpatient CAR T centers have emerged as a workaround, but these require major investments in space, staffing, and standardized toxicity management protocols. They also remain concentrated at large academic centers, leaving community practices without the resources to participate fully. Digital tools integrated into EHRs are being deployed to manage cytokine release syndrome and neurotoxicity, but not all institutions have these capabilities.

Ravi Vij, MD, MBA, professor of medicine at Washington University School of Medicine, noted that CAR T-cell therapies have much higher rates of toxicity and are less likely to be adopted in community settings in the near future. Bispecifics are easier to scale, though clinicians noted hesitancy to administer them during the ramp-up phase.

“We need to be aggressive in moving the science forward, but at the same time, you have to really make sure that this potentially would find its way to being given with comfort, with good education and resources provided to the community,” said Moh’d Khushman, MD, medical oncologist at WashU Medicine Siteman Cancer Center.

References
1. Chalabi M, Verschoor YL, Tan PB, et al. Neoadjuvant immunotherapy in locally advanced mismatch repair-deficient colon cancer. N Engl J Med. 2024;390(21):1949-1958. doi:10.1056/NEJMoa2400634
2. Haslam A, Hoeg TB, Prasad V. Estimation of eligibility for and response to CAR-T therapy in the United States. Blood Adv. 2023;8(4):1032-1036. doi:10.1182/bloodadvances.2023011184