Oncology Experts Call for Less Toxic Care, Smarter Access

Novel oncology therapies, from chimeric antigen receptor (CAR) T-cell therapy and bispecific antibodies to antibody-drug conjugates (ADCs), are reaching patients in earlier lines of treatment, but the systems needed to deliver them equitably and at the right intensity have not kept pace. Referral bottlenecks, concentrated trial infrastructure, and treatment durations inherited from trial protocols rather than patient response all remain barriers to value-based cancer care.

Those tensions framed “Pioneering the Next Era of Oncology Care,” an Institute for Value-Based Medicine^® event hosted by The American Journal of Managed Care in San Francisco on August 11, 2026. Clinicians and pharmacists from the University of California, San Francisco (UCSF) and Stanford University discussed those barriers across 3 panels.

Brain-to-Vein Time Emerges as the New CAR T Bottleneck

The first panel, “Advancing Frontiers in Leukemia & Lymphoma: Breakthroughs and Barriers,” was moderated by Madhav R. Seshadri, MD, an assistant clinical professor at UCSF who specializes in lymphoma and chronic lymphocytic leukemia. Mimi Lo, PharmD, BCPS, BCOP, a hematology/blood and marrow transplant (BMT) clinical pharmacist at UCSF, said moving CAR T-cell therapies and bispecifics into earlier lines of treatment has created operational demands around drug acquisition, inpatient step-up dosing, and outpatient administration.

Vanessa Kennedy, MD, an assistant professor at Stanford specializing in BMT and cellular therapy, said the core access challenge has shifted over the past 5 years. “Originally, I think there was a lot of focus on vein-to-vein time. How quickly can we get the product into the patient?” she said. “And now I think it’s really moving toward what I call brain-to-vein time, where [it’s] how quickly can you get from first thinking, ‘I think this patient should get a cellular therapy’ to actually getting them into a clinic where that cellular therapy could be administered.”

Edna Cheung, PharmD, BCOP, an inpatient hematology/oncology BMT clinical pharmacist at Stanford, attributed much of the gap between scientific potential and daily practice to logistics, including formulary restrictions and local housing for patients traveling from remote areas. Later, discussing bridging therapy delays, she pointed to hospital bed capacity: “We literally get an email every day about patients who are canceled because the hospital is too full.”

Tian Yi Zhang, MD, PhD, a translational leukemia physician at Stanford, said acute myeloid leukemia has lagged behind lymphoma in immunotherapy gains because the disease is “incredibly heterogeneous,” leaving few reliable targets beyond CD33. She described an investigator-initiated trial adding the CD123-directed agent tagraxofusp to chemotherapy for patients whose disease was refractory to frontline hypomethylating agents plus venetoclax, noting that its intensive inpatient monitoring limited access for patients living far from Stanford.

“There is what you want to do for the patient optimally, biologically, and with evidence, [and] then there is really what you can do for them because you have to do something,” Zhang said.

On sequencing bispecifics and CAR T-cell therapy, Kennedy said that depending on disease aggressiveness and where a patient lives, “sometimes the therapy you can access the quickest and the most reliably is the best therapy you have.” Cheung cautioned that prolonged bispecific exposure could exhaust the T cells needed for later CAR T-cell collection.

Kennedy called patient navigators and dedicated pathways “one of the single best interventions” for closing the referral gap. Seshadri said community uptake of bispecifics had improved markedly in the past year; he now typically administers the first 2 glofitamab cycles through the highest-risk window for cytokine release syndrome and neurotoxicity before community centers continue treatment locally. Lo said it was encouraging that Kaiser Permanente and Sutter Health had begun offering CAR T-cell therapy, and Zhang cited outpatient initiation of blinatumomab as “another success story.”

Sustainability Planning Must Precede Trial Launch

The second panel, “Collaborations in Today’s Environment for Successful Clinical Trials,” was moderated by Katherine Van Loon, MD, MPH, director of the Global Cancer Program at UCSF, who described clinical trial infrastructure as “a luxury item” concentrated in a few institutions. Manali I. Patel, MD, MPH, MS, FASCO, a professor in the Division of Oncology at Stanford and a thoracic oncologist at the Veterans Affairs Palo Alto Health Care System, argued that payment for effective interventions must be addressed before a trial begins.

“One of the key aspects before we do any trial is, think about the sustainability,” Patel said. “If something is effective, who is going to pay for that?”

In a study that brought biomarker testing to Salinas in Monterey County, California, Patel’s team formed a trial-specific community advisory board that included a local Medicare Medi-Cal payer, which agreed to eliminate prior authorization and help fund the $6000-per-test assay after the trial ended. More than 5 years later, she said, the intervention remained part of usual care. Trever G. Bivona, MD, PhD, a professor of medicine and thoracic oncologist at UCSF, said diagnostic tests with CMS coverage could address “the cliff after trial” by establishing payer coverage at diagnosis.

Samuel L. Washington III, MD, MAS, an associate professor of urology and urologic oncologist at UCSF, said a strategy led by Kim Rhoads, MD, MPH, MS, then an associate professor of epidemiology and biostatistics at UCSF, director of the Office of Community Engagement, and associate director for community outreach and engagement at UCSF Helen Diller Family Comprehensive Cancer Center, that advertised trials at community events and public transit locations left UCSF’s trial participation looking “closer to our catchment area than we had expected.”

Bivona called patient advocacy groups “a sleeping giant,” noting that UCSF’s ALK-positive lung cancer trial portfolio grew from 2 trials to 6 or 7 over approximately 5 years, driven partly by the ALK Positive advocacy group. Bridget Keenan, MD, PhD, an assistant professor at UCSF who works on early-phase immunotherapy trials, said patients had been fronting sponsor-reimbursable travel and lodging costs, sometimes on credit cards, which prompted a push for dedicated reimbursement staff.

“Potentially small things to you as a clinician are not small things to a patient,” Keenan said. Van Loon highlighted pragmatic trial designs with relaxed eligibility criteria and optional correlative sampling, noting that not every patient can spend 9 hours in an infusion center for pharmacokinetic draws.

Patel said that she spends less than 1% of an average week on actual science because of paperwork and reporting on low-risk outcomes and that delayed sponsor funding hits community partners hardest. She urged sponsors to streamline protocols, reporting, and meeting requirements.

“Really trying to go back to the carrot model is what we’re going to need to make sure that we don’t burn out, because I feel like I’m burnt out right now,” Patel said.

Panelists Question Broad Use of T-DXd in Early HER2-Positive Disease

The final panel, “Targeted Success: Operationalizing Therapies in Breast Cancer,” was moderated by Laura Esserman, MD, MBA, director of the UCSF Carol Franc Buck Breast Care Center, who said patients and advocates in her I-SPY (NCT01042379), RECAST (NCT06075953), and WISDOM (NCT02620852) studies consistently asked for less toxic therapy. Esserman questioned FDA approvals that made trastuzumab deruxtecan (T-DXd) followed by a taxane, trastuzumab (Herceptin), and pertuzumab (THP) a standard option in early HER2-positive breast cancer for all patients, not only those with node-positive disease, asking why clinicians would not start with THP and move to T-DXd for patients who did not respond.

Lidia Schapira, MD, FASCO, a professor of medicine at Stanford and inaugural director of Stanford’s Cancer Survivorship Program, said clearance language and National Comprehensive Cancer Network guideline wording had made it “inviting to treat everybody” with T-DXd, when some of her colleagues believed it was unneeded. She estimated that 9 patients would need 4 neoadjuvant cycles in DESTINY-Breast11 (NCT05113251) to yield 1 additional pathologic complete response (pCR) and that 12 would need 14 adjuvant cycles for 1 additional success, against a risk of potentially fatal pneumonitis.

“I personally am afraid of exposing somebody to harm when I’m treating somebody with curative intent, and I think that the threshold for prescribing this drug should be high,” Schapira said.

Tiffany Meng, PharmD, an oncology pharmacist at UCSF with a special interest in breast cancer, said prescribing varied by provider and depended on later ADC sequencing and any history of lung disease. Esserman said that when I-SPY investigators paired T-DXd with an investigational TIGIT-targeting agent, they performed high-resolution imaging every 6 weeks and stopped the drug at the first ground-glass opacities and no patient developed pneumonitis.

“Today, nobody should die from HER2 therapy,” she said. She also proposed paying manufacturers a single price per treatment course regardless of cycle count, arguing that companies would then be “first to want to help us run trials to figure out who needs what.”

Esserman cited KEYNOTE-522 (NCT03036488), in which she said patients who achieved pCR had similarly high survival in the pembrolizumab and control arms, to question a full year of adjuvant immunotherapy after pCR. She described a 35-year-old patient with a complete response who died of immune-related liver failure approximately 9 months into adjuvant pembrolizumab.

Meng identified a cultural driver of overtreatment. “I think all of us have to accept the responsibility that we are afraid,” Meng said. “We’re more afraid of making the mistake of not giving enough than afraid of the problem of giving somebody toxicity that can be lifelong.”

Schapira noted that as oral regimens add agents to endocrine backbones, “the burden’s on them,” proposing routine electronic symptom assessments with green, yellow, and red triage. Meng said staffing limited UCSF’s specialty pharmacy follow-up calls and that restricting high-cost targeted therapies to specialty pharmacy dispensing hindered equitable access. Esserman predicted that artificial intelligence applied to standard pathology slides would become “a great equalizer” for risk profiling within 5 years and urged de-escalation of surgery after strong responses. “Stop doing it until there are data that show that more is better,” she said.

Across all 3 panels, speakers converged on a shared message for payers, sponsors, and health systems: Precision should govern not only which target a therapy hits but who receives it, for how long, and where. Esserman closed the evening with a plug for personalized screening through the WISDOM study.

“More screening isn’t better,” she said. “More personalized screening is better.”