Barriers to Allogeneic Hematopoietic Cell Transplantation in the Haploidentical Era: A Multicenter...

Despite advances in donor availability and transplant techniques, many patients who are eligible for allogeneic hematopoietic cell transplantation (allo-HCT) never undergo the procedure. This gap is particularly pronounced in low- and middle-income countries (LMICs), where structural and clinical barriers may limit access. To identify barriers to undergoing allo-HCT among HLA-typed, transplant-eligible patients, and to assess transplant rates, associated factors, and outcomes. We conducted a multicenter retrospective cohort study of adult patients with hematologic diseases deemed eligible for allo-HCT who underwent HLA typing between January 2015 and March 2020 at 3 referral centers in Mexico. Primary outcome was to identify barriers to transplantation; secondary outcomes included cumulative incidence of allo-HCT, overall survival (OS), and factors associated with undergoing allo-HCT. Analyses were conducted on an intent-to-transplant basis. Among 374 eligible patients, the 2-year cumulative incidence of allo-HCT was 53% (95% CI, 47-58). The most common barrier was disease progression (58%), followed by inpatient bed shortages (35%) and comorbidities (32%). Donor unavailability accounted for only 12% of nontransplant cases. In the multivariate analysis, outpatient care (OR 6.7; 95% CI, 4.1-10.9) and government insurance (OR 1.9; 95% CI, 1.2-3.2) were associated with higher transplant access while high/very high Disease Risk Index (OR 0.4; 95% CI, 0.2-0.7) was associated with reduced likelihood of transplant. The landmark analysis showed improved overall survival (OS) in transplanted patients (30 vs. 12 months; P < .001). Cumulative incidence of transplant-related mortality was 21% at 24 months. In this multicenter intent-to-transplant cohort from a LMIC, disease progression and systemic delays were the leading barriers to allo-HCT. While haploidentical transplantation minimized donor limitations, outpatient transplant models and national insurance coverage emerged as key enablers of access. Expanding outpatient models and strengthening public systems are key to improving equity in transplant delivery.