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Overcoming Barriers to HCT and Improving Access

Explore Cell Therapy podcast season 2, episode 2 recap 

In this two-part episode, our expert guests discuss recent research around access to HCT, as well as overcoming HCT barriers through coordinated care between transplant centers and hematology/oncology practices.

Karen Ballen, MD, of University of Virginia Health, and Mitul Gandhi, MD, of Virginia Cancer Specialists, explore barriers to HCT from a research and practice perspective and examine potential solutions across transplant centers, hematology/oncology practices, and even health care policy. 

Listen to the full discussion between Dr. Ballen and Dr. Gandhi now!

  • Part 1: Barriers in HCT and the Importance of Time
  • Part 2: Health Equity, Solutions and Building Trust via Shared Care

Meet this episode's expert guests 

Karen Ballen Photo for Podcast Post

Karen Ballen, MD

Medical Director, Stem Cell Transplant Program
Division Chief of Hematology/Oncology 
Professor of Medicine, University of Virginia Health

Dr. Ballen's career at the University of Virginia has been devoted to the care of leukemia and transplant patients. Her clinical research expertise is in alternative donor transplantation and transplant outcomes. In addition to serving as a professor of medicine, Medical Director of the Stem Cell Transplant Program, and Division Chief of Hematology/Oncology, she serves as the Chair of the Cord Blood Advisory Committee for the NMDP. 

 

Mitul Gandhi Photo for Podcast PostMitul Gandhi, MD

Hematologist
Director of Stem Cell Therapy
Hematology Lead CAR-T and Cellular Therapy
New York Oncology Hematology
Cancer Committee Chair Albany Medical Center
Clinical Assistant Professor Albany Medical Center

Dr. Gandhi earned his medical degree from Rutgers Robert Wood Johnson Medical School, where he received the Robert Wood Johnson Foundation Research Award among other honors. Dr. Gandhi then completed his residency and internship at University of Michigan Health System. He joined Virginia Cancer Specialists after serving as Chief Fellow in the Medical Oncology and Hematology Fellowship program at Northwestern University Feinberg School of Medicine. During his time at Northwestern, Dr. Gandhi actively participated in clinical research, with a focus in high-risk lymphoma. Dr. Gandhi is currently an Associate Member of both the American Society of Hematology (ASH) and the American Society of Clinical Oncology (ASCO).

Part 1: Barriers in HCT and the Importance of Time episode recap

 Listen to Part 1 

In part one of this two-part episode, Dr. Ballen discusses major findings from her recent publication in Transplantation and Cellular Therapy on barriers in HCT. Dr. Gandhi provides hematology/oncology context and explores the importance of early consultation to give patients, caregivers, and providers more time to ensure optimal HCT outcomes.

Recent research on barriers in HCT 

Dr. Ballen opens the episode with a discussion of her recent publication reporting barriers to HCT in the Virginia area where both she and Dr. Gandhi practice. While finding a donor may be less of a barrier to HCT, Dr. Ballen expresses the importance of exploring other barriers to transplant and understanding who ultimately gets a transplant and who doesn't. Partnering with the Virginia Department of Health and the NMDP leveraging data from the CIBMTR® (Center for International Blood and Marrow Transplant Research®), the study examined patients with acute myeloid leukemia (AML) to determine what factors influenced whether or not they went on to transplant. 

According to Dr. Ballen, findings showed that only 21% of adult patients with AML who may benefit from a transplant actually get one in the state of Virginia. Virginia has some of the richest and poorest counties in the United States, with richer and more urban centers in northern Virginia closer to Washington, D.C., and more rural and poorer areas to the south. When broken down by region, those living in northern Virginia had a higher chance of going on to transplant, as did those who were married or had a partner. Patients from geographical regions with a more than 25% African American population, those with government insurance payors like Medicare or Medicaid, those with less than a college-level education, or those with a higher Social Vulnerability Index (SVI: a composite index used by the Centers for Disease Control and Prevention to identify at-risk communities) were all less likely to go to transplant. This was the first time that SVI was applied in the HCT or hematology/oncology field.

As Dr. Ballen emphasizes, data suggest that many patients who could benefit from transplant regardless of having a donor don't have access. Dr. Gandhi corroborated many of these barriers at the hematology/oncology level, expressing that geographic and transportation challenges are especially a barrier to treatment at a transplant center that may be quite far from home. 

The importance of timing and early consultation 

As Dr. Gandhi continues, he discusses how the complexities of the road to transplant make early consultation and extra time to address these barriers so important. When patients are just taking in the news of how to deal with their diagnosis and then must think about traveling far away to consider transplant, it can become a real challenge.

Dr. Gandhi specifically notices geographic hesitation from patients unable to uproot their lives and be away from family support, and he often sees financial concerns about the process. Government-sponsored insurance barriers can also be very difficult to overcome. However, Dr. Ballen and Dr. Gandhi both express the need for early referral.

According to Dr. Gandhi and Dr. Ballen, seeing patients early in their disease course allows a transplant center and hematology/oncology practice the chance to work together to help overcome barriers for patients. This gives the patient and care team more time to figure out the logistics of transplant, especially when transplant may already have a narrow window to ensure ideal outcomes. The NMDP partners with the American Society for Transplantation and Cellular Therapy (ASTCT) to publish HCT Consultation Timing Guidelines  to help hematology/oncology providers know when it's the right time to contact a transplant center.

Dr. Gandhi also discusses how the concept of what HCT is today has changed dramatically from what it was years ago, even when he was training. Not only patients, but hematology/oncology providers may hold onto this outdated idea of transplant that can lead to hesitations when considering consultation for their patients (listen to the Advances in HCT Over Time episode series to learn more). Dr. Gandhi says age is another factor that he sees stand in the way of HCT consideration, despite advances making functional fitness more important than chronological age when considering HCT eligibility or quality of life. Confirming the importance of continuing education for all providers, Dr. Ballen stresses that early consultation also helps with the challenging patient education process and provides extra time to connect patients with other patient ambassadors who have already gone through transplant and can help shed light on the process. The more coordinated care is — with rapid and frequent communication between transplant centers and hematology/oncology practices — the smoother the process is for patients. 

Part 2: Health Equity, Solutions and Building Trust via Shared Care episode recap  

 Listen to Part 2 

In part two of this two-part episode, Dr. Ballen and Dr. Gandhi touch on health equity and disparities in access for racially and ethnically diverse patients. They go on to propose solutions at the provider, patient, and policy level, and stress the importance of shared and coordinated care between providers to build trust and improve patient outcomes and experience. 

Disparities and improving equity in HCT 

Dr. Ballen starts by addressing disparities in donor availability for patients who are ethnically diverse, acknowledging that it is easier for non-Hispanic white patients to find a fully matched donor on the NMDP Registry. However, she goes on to discuss modern techniques in HCT that continue to expand access for these patients. With advances in mismatched unrelated donor (MMUD) HCT and improved outcomes, the NMDP Registry is able to identify a MMUD for nearly 100% of patients in need of transplant.  

Dr. Ballen specifically calls attention to the currently enrolling ACCESS trial. This trial is a continuation of the NMDP-sponsored 15-MMUD study that examined the use of post-transplant cyclophosphamide (PTCy) as a way to prevent graft-versus-host disease (GVHD) in MMUD HCT. Survival and relapse outcomes remained strong at both 1- and 3-year follow-up. A remarkable 48% of patients enrolled were ethnically diverse, validating the potential of MMUD to expand HCT access to racially and ethnically diverse patients.  

Proposing potential solutions to overcome barriers to HCT 

Dr. Ballen and Dr. Gandhi continue to discuss disparity and barriers to care by identifying areas on the path to transplant that need additional support. For communities at risk, Dr. Ballen discusses the need for transportation and housing support, financial assistance for time off work and flexible leave, and looking holistically at how care is packaged for the patient. Dr. Gandhi agreed that many of these issues need to be addressed at the policy level, creating a policy structure that anticipates and better meets these needs.  

Dr. Gandhi and Dr. Ballen go on to discuss FACT accreditation needed to perform transplant-related procedures on site, mentioning the stringent policies as a potential barrier for community hematology/oncology practices to provide more direct care closer to home. Dr. Ballen does, however, promote the adoption of HLA Today, an NMDP  program offering free HLA typing to patients at community hematology/oncology practices to get the donor search process started and decrease time to transplant.  

  

Building trust through coordinated or shared care  

Finally, Dr. Gandhi and Dr. Ballen discuss the benefits of their strong professional relationship, citing how trust between providers in a patient's care team helps the patient feel more at ease during a difficult time. Dr. Ballen stresses the number of decision points that come into play in both hematology/oncology and transplant, so coming together as a coordinated team and trusting your expanded care team is imperative. Dr. Gandhi and Dr. Ballen both agree that an integrated health care model valuing nurse navigators, palliative care, infectious disease specialists, cardiologists, social workers, radiologists, and more translates to the best patient experience and ultimate outcomes.  

 

Looking forward, NMDP is partnering with Dana Farber Cancer Institute to produce shared care recommendations for hematology/oncology and transplant providers in HCT. Dr. Gandhi and Dr. Ballen reiterate the importance of shared care, confirming that their close relationship and frequent communication with one another makes all the difference. They also stress the need for health policy that accounts for the continuum of care to address barriers to transplant.  

 

Additional resources

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