复发/难治性大 B 细胞淋巴瘤患者 CAR-T 细胞治疗可及性：可及性与健康社会决定因素及到治疗中心出行时间的关联

Large B-cell lymphoma (LBCL) is the most common type of non-Hodgkin lymphoma. Chimeric antigen receptor T-cell (CAR T) therapy represents a novel treatment with curative potential for relapsed or refractory (R/R) LBCL, but there are access barriers to this innovative therapy that are not well-studied. Study objectives were: (1) Assess the impact of geographic factors and social determinants of health (SDOH) on access to treatment with CAR T in a sample of patients with R/R LBCL and 2 prior lines of therapy (LOT). (2) Compare and contrast patient characteristics, SDOH, and travel time between patients with R/R LBCL who received CAR T and those who did not. An observational, nested case-control study of patients with R/R LBCL, 2 prior LOT, not in a clinical trial, identified using 100% Medicare Fee-For-Service and national multi-payer claims databases. Patients were linked to near-neighborhood SDOH using 9-digit ZIP-code address. Driving distance and time between residence and nearest CAR T treatment center (TC) was calculated. Patients were stratified based on treatments received upon third LOT initiation (Index Date) or later: (1) received CAR T and (2) did not receive CAR T.

Multivariable logistic regression was used to evaluate factors associated with CAR T. 5011 patients met inclusion criteria, with 628 (12. 5%) in the CAR T group. Regression models found the likelihood of receiving CAR T decreased with patient age (odds ratio [OR] = . 96, P < . 001), and males were 29% more likely to receive CAR T (OR = 1. 29, P = . 02). Likelihood of CAR T increased with Charlson Comorbidity Index (CCI; OR = 1. 07, P < . 001) indicating patients with more comorbidities were more likely to receive CAR T.

Black patients were less than half as likely to receive CAR T than White patients (OR = . 44, P = . 01). Asian patients did not significantly differ from White patients (OR = 1. 43, P = . 24), and there was a trend for Hispanic patients to have a slightly lower likelihood of CAR T (OR = .

50, P = . 07). Higher household income was associated with receipt of CAR T, with the lowest income group more than 50% less likely to receive CAR T than the highest (OR = . 44, P = . 002), and the second lowest income group more than 30% less likely (OR = . 68, P = . 02).

Finally, likelihood of CAR T therapy was reduced when the driving time to the nearest TC was 121 to 240 minutes (reference group: 30 minutes; OR = . 64, P = . 04). Travel times between 31 and 121 or greater than 240 minutes were not significantly different from 30 minutes. Payer type was collinear with age and could not be included in the regression analysis, but patients with commercial insurance were 1. 5 to 3 times more likely to receive CAR T than other payers on an unadjusted basis.

We identified significant disparities in access to CAR T related to demographics and SDOH. Patients who were older, female, low income, or Black were less likely to receive CAR T. The positive association of CCI with CAR T requires further research. Given the promising outcomes of CAR T, there is urgent need to address identified disparities and increase efforts to overcome access barriers.