Transplant Equity Requires Policy and Accessible Trials

When it comes to closing gaps in access to allogeneic stem cell transplant, Karilyn Larkin, MD, see the greatest urgency beyond the clinic and the lab. “I do feel like the policy space might be the most equitable, far-reaching thing,” said Larkin, director of clinical and translational research for myeloid malignancies at Wilmot Cancer Institute and formerly of The James.

Mandated transplant coverage that includes caregiver support and housing, she argued, would ease disparities driven by institutional resources and employer benefits. Coverage should reflect “the bare minimum that people deserve to be able to fight the same disease in the same way,” she said. She recalled a recent hospice patient whose employer planned to fire him because insurance premiums threatened to bankrupt the company. Still, she is least hopeful about policy change.

Research is another matter. Larkin is optimistic that growing attention and faster, systematic data collection will speed discoveries. The harder step is ensuring the next person diagnosed with acute myeloid leukemia from a smaller area reaches a transplant center. Distance, she believes, shapes whether patients pursue transplant, get referred, and potentially how they fare. It also limits trial enrollment. Many centers, including hers, require patients to stay within about 30 minutes for 100 days, and trials with monthly visits deter underresourced patients living 3 to 4 hours away.

The ACCESS trial (NCT04904588), which tested mismatched unrelated donors using peripheral blood stem cells, succeeded partly because it avoided those burdens. There were no monthly visits or inventoried study drugs, just data collection and occasional calls. For many participants, it was the only route to transplant.

“It was a very well-designed and sort of easy to get into type of trial,” she said.

Institutions should build trial portfolios that ask less of patients without sacrificing end points, she said. Dono availability is no longer a barrier, but infections and relapse remain concerns she loses sleep over. The next phase, she said, depends on getting the benefits of transplant to the people who need them.