Stark Insurance and Racial Disparities Seen in Analysis of National CAR T-Cell Data

An analysis of national inpatient data has revealed significant insurance-based and racial disparities in both access to and outcomes from chimeric antigen receptor (CAR) T-cell therapy, which the authors say raise both policy and clinical questions about equity for one of the most transformative cancer treatments of the last decade.¹

The authors, from New York Medical College and Rutgers University, say theirs is “the first national analysis to reveal profound insurance-based mortality gaps in CAR T therapy.”¹

Presented as a poster during the recent 2026 annual meeting of the American Society of Clinical Oncology (ASCO), this retrospective analysis used the National Inpatient Sample (2020–2022) to identify CAR T-cell therapy recipients through ICD-10-PCS procedure codes across FDA-approved indications. The cohort encompassed 10,610 weighted CAR T-cell therapy hospitalizations. Patients had a mean age of 59.4 years, with 62.1% being male, and 97% were treated at academic centers. The most common indication was diffuse large B-cell lymphoma (DLBCL), which accounted for 46.9% of cases, followed by multiple myeloma (25.0%) and B-cell acute lymphoblastic leukemia (12.7%).¹

Overall, in-hospital mortality across the cohort was 8.6%, while cytokine release syndrome (CRS) occurred in 42.3% of patients and immune effector cell-associated neurotoxicity syndrome (ICANS) in 19.7%.¹

The authors found that insurance-based disparities were particularly alarming: Compared with privately insured patients, who had an in-hospital mortality rate of 5.5%, both Medicare and Medicaid patients fared significantly worse. Medicare patients experienced a mortality rate of 11.5% (adjusted odds ratio (aOR) of 1.59; 95% CI, 1.32–1.92; P < .0001), while Medicaid patients had a mortality rate of 10.7% (aOR 1.89; 95% CI, 1.45–2.47; P < .0001).

These differences persisted after multivariable adjustment for age, sex, race, comorbidities, and disease indication, and the authors found they worsened over time. According to the abstract, the Medicare-to-private insurance mortality ratio increased from 1.9x in 2020 to 2.2x in 2022, suggesting the gap is not narrowing as CAR T-cell therapy matures and expands.

Racial disparities were evident in both access and outcomes. According to the poster presentation, Black patients represented just 9.1% of CAR T recipients despite comprising 13.6% of the US population, meaning they received the therapy at approximately 67% of the expected rate. Hispanic patients were similarly underrepresented, accounting for 13.7% of CAR T recipients vs 18.9% of the general population, or approximately 72% of their expected share. Together, these figures indicate that both groups face substantial systemic barriers to accessing CAR T-cell therapy even as indications continue to broaden to include conditions such as DLBCL, where the therapy has demonstrated significant survival benefit.²

Among Black patients receiving CAR T-cell therapy, a pattern emerged. “Black patients who do receive CAR T-cell therapy demonstrate distinct toxicity phenotypes with higher neurotoxicity and ICU [intensive care unit] utilization,” the authors wrote, citing higher rates of immune effector cell-associated neurotoxicity syndrome, or ICANS (aOR 1.38; 95% CI, 1.16–1.64; P = .0003) as well as ICU rates (23.8% vs 16.6% for White patients) and mechanical ventilation (12.4% vs 8.1%).

Conversely, Black patients had lower rates of CRS (aOR 0.79; 95% CI, 0.68–0.91; P = 0.001). The biological or socioeconomic mechanisms underlying this differential toxicity profile warrant further investigation, the authors stated. No significant sex-based mortality differences were identified.

The study authors characterized this as the first comprehensive national analysis of insurance-based and racial disparities in CAR T therapy. They called for targeted interventions to reduce access barriers and to optimize outcomes across all patient populations. Today, there is a push to bring CAR T-cell therapy and bispecific treatments into community practices and outpatient clinics to reduce driving distance and other barriers to access.³ However, these efforts are offset by changes to Medicaid that could make it more challenging for some patients to maintain insurance eligibility.

Earlier studies have highlighted insurance and racial disparities in CAR T outcomes, but not with a comprehensive national data set. In 2024, Ahmed and Grover reached similar conclusions in Blood using data for patients with DLBCL and follicular lymphoma from 13 US academic centers, gathered between 2015 and 2021.⁴ Ahmed and Grover highlighted the relative lack of access to clinical trials for Black and Hispanic patients, as the first CAR T-cell therapies were not approved until 2017. This disparity has been noted as especially glaring in diseases such as multiple myeloma, which affects the Black population at disproportionate rates.⁵

Such disparities in clinical trial enrollment led the FDA to issue draft guidance compelling pharmaceutical sponsors to develop plans to ensure that drug trials reflect populations receiving therapies. The guidance was finalized in December 2025.⁶

The study’s lead author is Jeril Lasington, MBBS, MS, who is affiliated with The New York Medical College Graduate Medical Education Program at St. Mary’s General Hospital and St. Clare’s Health in Denville, New Jersey.

References

1. Lasington J, Lawin S, Lasington M, Dirican CD. Insurance and racial disparities in CAR T-cell therapy outcomes: A national inpatient analysis. J Clin Oncol. 2026;44(suppl 16):abstr 11172. DOI: 10.1200/JCO.2026.44.16_suppl.11172
2. Thalambedu N, Kumaran M, Gaddam M, et al. Impact of the CAR-T era on survival in diffuse large B-cell lymphoma: A US population-based cohort study. Blood. 2025;146(Supplement 1):6334. doi:10.1182/blood-2025-6334
3. Caffrey M. CAR T on Main Street: COA session dives into details on expanding access to care. AJMC^®. April 29, 2026. Accessed June 12, 2026. https://www.ajmc.com/view/car-t-on-main-street-coa-session-dives-into-details-on-expanding-access-to-care
4. Ahmed N, Grover NS. Race and insurance: real-world insights on CAR-T outcomes. Blood Adv. 2024;8(10):2589-2591. doi:10.1182/bloodadvances.2024013148.
5. Flinn R, Caffrey M. As myeloma trials tackle frontline treatment, where are the Black patients? Am J Manag Care. 2024;30(Spec. No. 12):SP952-SP956. doi:10.37765/ajmc.2024.89691.
6. Enhancing Participation in Clinical Trials — Eligibility Criteria, Enrollment Practices, and Trial Designs; Guidance for Industry. FDA. Published December 2025. https://www.fda.gov/media/190162/download