Who Is Eligible for Chimeric Antigen Receptor T Cell Therapy? Expert Perspectives on Overcoming Referral Barriers

CD19-directed chimeric antigen receptor T-cell (CAR-T) therapies, including lisocabtagene maraleucel, axicabtagene ciloleucel, and tisagenlecleucel, have revolutionized the treatment landscape for patients with hematologic malignancies. However, identification and referral of patients who could benefit from treatment remains a significant challenge, Here, we report expert recommendations for CAR-T therapy referral gathered from 10 experts in oncology, hematology, cardiology, and infectious diseases from a roundtable meeting and/or subsequent reviews between November 13, 2024, and June 9, 2025. We considered the following potential factors: age, performance status, disease status, cardiovascular function, pulmonary function, renal function, hepatic function, infections, and psychological health. Based on existing evidence, we agreed that none of the factors discussed should preclude patients from receiving referrals/further evaluation for CAR-T therapy, particularly with current advances in supportive care and integration of services from other specialties. Timely referral should be made by the patient's primary oncologist to specialists as early as the disease is deemed relapsed or refractory, preferably before the starting the subsequent line of therapy to allow better access to care and improve treatment outcomes. Before CAR-T therapy, holding therapy (before leukapheresis) and/or bridging therapy (after leukapheresis) may be given to patients with high-volume disease, in consultation with CAR-T therapy specialists. Based on the safety profile of CAR-T therapies, experts recommended flexible monitoring and transfer of care back to primary/community oncology physicians, starting from 2 weeks after infusion to improve access to this potentially curative therapy. Adaptations to clinical practice based on the most recent regulations, policy requirements, and institutional guidelines should be made as needed. In summary, a panel of 10 experts provided recommendations for timely patient referral for CAR-T therapy on the occurrence of relapsed or refractory disease and before the initiation of subsequent lines of therapy to improve care access and treatment outcomes. Experts noted that with close collaboration between CAR-T therapy specialists and other medical disciplines, CAR-T therapy remains a feasible option for most patients despite their comorbidities. © 2025 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.