Introduction: Chimeric antigen receptor T-cell (CAR-T) therapy has revolutionized treatment for select hematologic malignancies. Despite its established clinical benefit, access remains inequitable, particularly in underserved communities. National data show marked disparities by race, insurance status, geography, and socioeconomic status. African American patients, Medicaid recipients, and rural populations are consistently underrepresented among CAR-T recipients. Such disparities persist even close to academic centers, suggesting multiple barriers to access, which is especially concerning given CAR-T's expanding use in earlier lines of therapy. We conducted a retrospective study to evaluate real-world barriers to CAR-T access at a tertiary cancer center serving a predominantly underserved population in northwestern Louisiana.

Methods: We conducted a retrospective study of adult patients (≥18 years) deemed eligible for CAR-T therapy between January 1, 2023 and May 27, 2025 at a tertiary academic center serving northwestern Louisiana. Demographics, insurance status, diagnosis, area of residence, travel time to the nearest CAR-T center, and clinical outcomes were recorded. Reasons for not receiving CAR-T were documented. Descriptive statistics were generated using JASP 0.95.0.

Results: A total of 39 patients were confirmed as CAR-T eligible. The median age was 63 years (IQR: 56–70), with 23 (59%) male and 16 (41%) female patients. The racial distribution was 22 (56.4%) African American, 16 (41%) White, and 1 (2.6%) Hispanic. Most patients (29, 74.4%) resided in urban/metropolitan areas. The median travel time to the nearest CAR-T center was 170 minutes (IQR: 146–194). Among patients, 21 (53.8%) had Medicare, 10 (25.7%) had private insurance, 7 (17.9%) had Medicaid, and 1 (2.6%) had VA coverage. The most common diagnoses were multiple myeloma (18/39, 46.2%), diffuse large B-cell lymphoma (DLBCL; 12/39, 30.8%), acute lymphoblastic leukemia (6/39, 15.4%), follicular lymphoma (2/39, 5.1%), and mantle cell lymphoma (1/39, 2.6%). Out of 39 eligible patients, 16 (41%) were referred for CAR-T, but only 8 (20.5%) received it. Of the 8 patients treated, 4 (50%) had DLBCL, 3 (37.5%) had multiple myeloma, and 1 (12.5%) had follicular lymphoma. Among the 31 (79.5%) patients who did not receive CAR-T, the most common barriers included lack of insurance coverage (9, 29%), transportation or social support limitations (9, 29%), refusal to travel out of city/state (6, 19.4%), clinical deterioration or death before treatment (5, 16.1%), unknown reasons (5, 16.1%), and preference for less intense or bispecific T-cell engager therapy (4, 12.9%). Among those who received CAR-T, 4 (50%) had Medicare and 4 (50%) had private insurance. All 7 patients on Medicaid cited lack of insurance coverage as the reason for non-receipt of CAR-T.

Conclusions: In this medically underserved population, only 20.5% of eligible patients received CAR-T. The most frequently cited barriers included lack of insurance coverage (29%), transportation or social support limitations (29%), and refusal to travel outside the region (19.4%). These findings underscore the persistent influence of structural, financial, and geographic disparities. Although coverage for CAR-T therapy under Louisiana Medicaid was initiated in August 2023 following the enactment of House Bill 435, all 7 Medicaid recipients in our study cited lack of insurance coverage as the reason for non-receipt of CAR-T. These findings highlight the lag between policy implementation and real-world impact. Further reforms may be necessary to streamline referral processes, remove administrative burdens, and ensure continuity of coverage across institutions and care settings. Expansion of Medicaid benefits alone may not suffice without parallel efforts to address nonfinancial barriers to care. Supporting this, SEER-Medicare data (Chung et al.) show that reducing travel distance from 104 to 34 miles could increase CAR-T utilization by 38% in DLBCL patients. In our cohort, the median travel time to a CAR-T center was 170 minutes which highlights the need for localized treatment infrastructure. Establishing CAR-T capabilities including access to cellular therapy clinical trials at Ochsner LSU Shreveport, a large academic referral center for northwestern Louisiana, may be a critical step toward reducing access inequities and improving outcomes for historically marginalized and medically underserved populations.

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2025
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