Real-world barriers to treatment access in T-cell lymphoma

Abstract Introduction T-cell lymphomas (TCL) are associated with limited therapeutic options and poor outcomes. Identifying real-world barriers to treatment is essential to inform strategies that optimize care delivery and improve outcomes in this underserved population. Methods We conducted a retrospective review of patients with a primary diagnosis of TCL who were seen at the Fred Hutchinson Cancer Center/University of Washington. Clinical and demographic data were extracted from electronic medical records. Associations between patient characteristics and type of treatment received were analyzed using Wilcoxon rank sum tests for continuous variables and Pearson's Chi-squared or Fisher's exact tests for categorical variables, as appropriate. Results Between 2014 and 2024, 400 patients were identified. Males comprised 61% of patients. The majority of patients (69%) were non-Hispanic whites, with Asians/Pacific Islanders, Hispanics/Latinos, and African Americans comprising 13%, 8.4%, and 7.2%, respectively. The most common TCL subtypes were peripheral TCL not otherwise specified (PTCL-NOS; 28%), large granular lymphocytic leukemia (LGL; 17%), nodal T follicular helper (TFH) lymphoma (17%), anaplastic large cell lymphoma (ALCL; 16%), and primary cutaneous TCL (CTCL; 8%), with other subtypes comprising 15%. Eighty-nine percent of patients had insurance coverage: 32% were enrolled in commercial PPO plans, 29% in Medicare, 15% in Medicaid, and 7.8% in commercial HMO plans; 11% of patients were uninsured. The median number of treatment lines was 2 (range, 0–11); 5.8% of patients received an autologous stem cell transplant (SCT), 17% an allogeneic SCT, and 77% neither as part of their treatment course. Fifty-six percent of patients received at least one novel agent during their treatment, while 27% received only conventional chemotherapy. Seven percent participated in at least one clinical trial. Among patients with CD30+ disease, 36% were treated with a brentuximab vedotin (BV)-containing regimen. Treatment patterns varied significantly by TCL subtype (p < 0.001). Patients with ALCL and nodal TFH lymphoma were most likely to receive at least one novel or experimental agent (77% and 59%, respectively). In contrast, those with LGL and CTCL more often received therapies outside of conventional chemotherapy or novel agent–based regimens (51% and 50%, respectively). Patients with PTCL-NOS demonstrated a more even distribution, with 36% receiving only conventional chemotherapy and 36% receiving at least one novel agent. Among patients with CD30+ disease, receipt of BV was significantly associated with insurance status (p = 0.001); only 4.8% of uninsured patients received BV compared to 41% of insured patients. Insured patients were 6.4 times more likely to receive BV as part of first-line therapy than uninsured patients (32% vs 5%, respectively, p = 0.013). Clinical trial participation varied significantly by both insurance status and TCL subtype. While 7.8% of insured patients enrolled in at least one clinical trial, no uninsured patients participated. The highest enrollment was observed among patients with commercial HMO insurance (19%), followed by commercial PPO, Medicare, and Medicaid(9.3%, 6.0%, 5.1%, respectively, p = 0.025). Participation differed by diagnosis (p = 0.029), with ALCL patients showing the highest enrollment (14%) and PTCL-NOS the lowest (1.8%). Conclusion Real-world treatment patterns in TCL vary significantly by histologic subtype and insurance status, with notable disparities in access to novel therapies, BV, and clinical trial participation. These findings highlight the need for targeted efforts to address structural barriers in care delivery and ensure equitable access to emerging therapies in this patient population.