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. 2026 May 5;9(5):e2610839. doi: 10.1001/jamanetworkopen.2026.10839

Hematopoietic Cell Transplant Access and Patient Diversity

Rachel Cusatis 1,2,✉, Jianqun Kou 3, Caitrin Bupp 3, Deborah Mattila 3, Ramzi Abboud 4, Sally Arai 5, Javier Bolaños Meade 6, George Carrum 7, Bhagirathbhai Dholaria 8, Fatema Fareh 9, Mehdi Hamadani 1,10, William J Hogan 11, Katarzyna Jamieson 12, Antonio M Jimenez Jimenez 13, Farhad Khimani 14, Amar H Kelkar 15, Satyajit Kosuri 16, Karilyn T Larkin 17, Monzr M Al Malki 18, Shannon R McCurdy 19, Jordan Milner 20, Dipenkumar Modi 21, Ran Reshef 22, Brian C Shaffer 23, Krithika Shanmugasundaram 24, Uttam Rao 25, Jeffrey J Auletta 3, Steven M Devine 3, Brent R Logan 1,26, Bronwen E Shaw 1,2
PMCID: PMC13147192  PMID: 42084866

Key Points

Question

What is the association between broadening access to hematopoietic cell transplant through the use of mismatched unrelated donors and access for racially and ethnically underrepresented patients and socioeconomically or structurally disadvantaged populations?

Findings

In this cross-sectional study of 672 patients comparing the ACCESS trial, which enrolled patients without matched donors, with a similar clinical trial and a clinical cohort, ACCESS enrolled a more racially and ethnically diverse population (47% vs 15% and 9%, respectively) and participants with more social disadvantage and lower income.

Meaning

These findings suggest that broadening eligibility criteria may increase diversity and access to hematopoietic cell transplant, underscoring the need for systemic interventions to address persistent inequities.

This cross-sectional study examines the association between broadening access to hematopoietic cell transplant through mismatched unrelated donors and access for racially, ethnically, and socioeconomically diverse populations.

Abstract

Importance

Allogeneic hematopoietic cell transplant (HCT) is curative for hematologic cancers, yet access remains inequitable for racially and ethnically underrepresented and socioeconomically disadvantaged populations, making the goal of having a suitable donor for every patient who needs a transplant challenging. The ACCESS trial broadened access by enrolling patients without matched donors, who instead received an HCT from a mismatched unrelated donor.

Objective

To compare baseline characteristics of ACCESS trial participants with participants enrolled in a similar clinical trial and a patient-reported outcome (PRO) protocol cohort.

Design, Setting, and Participants

This cross-sectional study included adult participants (aged ≥18 years) from 3 cohorts—the ACCESS trial (2021-2024), BMT CTN 1703 trial (2019-2021), and Center for International Blood and Marrow Transplant Research (CIBMTR) PRO Protocol observational study (2020-2025)—who completed a baseline PRO survey. The ACCESS and PRO Protocol cohorts were stratified by conditioning intensity (myeloablative [MAC] vs reduced-intensity and nonmyeloablative [RIC/NMA]); all BMT CTN 1703 participants received RIC/NMA.

Exposure

Hematopoietic cell transplant.

Main Outcomes and Measures

Racial and ethnic diversity, insurance type, education, and income were compared among cohorts using counts and percentages, and socioeconomic and structural disadvantage were measured using the Social Vulnerability Index and Comprehensive Score for Financial Toxicity–Functional Assessment of Chronic Illness Therapy.

Results

Baseline surveys were completed by 208 participants in the ACCESS trial (median [range] age at transplant, 62.3 [20.4-78.9] years; 108 male [51.9%]), 122 participants in the PRO Protocol study (median [range] age at transplant, 63.9 [21.1-78.0] years; 67 male [54.9%]), and 342 participants in the BMT CTN 1703 trial (median [range] age at transplant, 66.9 [20.7-78.6] years; 218 male [63.7%]). Participants in ACCESS were more racially and ethnically diverse, with 15 (7.2%), 25 (12.1%), 46 (22.2%), 110 (53.1%), and 11 (5.3%) of Asian, Black or African American, Hispanic or Latino, White, and other race and ethnicity, respectively, compared with 4 (3.3%), 2 (1.6%), 8 (6.6%) 104 (85.2%), and 4 (3.3%), respectively, in the PRO Protocol and 10 (3.0%), 0, 16 (4.8%), 302 (91.0%), and 4 (1.2%), respectively, in the BMT CTN 1703 trial. Participants in ACCESS were more likely to have Medicaid (36 [18.1%]) vs PRO Protocol (8 [6.7%]) and BMT CTN 1703 (16 [5.1%]) participants and reported lower education (some college or an associate’s degree: 103 [49.5%] vs 73 [59.8%] in the PRO Protocol; postcollege education: 34 [17.3%] vs 35 [29.2%] in the PRO Protocol) and household income (<$40 000 annually: 25 [24.0%] vs 8 [11.6%] in the PRO Protocol and 7 [38.9%] in the BMT CTN 1703 trial). Median Social Vulnerability Index scores were highest among participants in the ACCESS MAC group (median [range], 0.72 [0.01-0.97] vs 0.61 [0.16-0.78] in the PRO Protocol MAC group), and 16 participants [27.6%] in the ACCESS MAC group reported moderate to severe financial toxicity. The ACCESS participants lived closer to transplant centers, especially in the RIC/NMA group (median [IQR], 28 [14-75] miles vs 47 [16-96] miles for BMT CTN 1703 participants and 49 [21-104] miles for PRO Protocol participants).

Conclusions and Relevance

This cross-sectional study of clinical trial participants and a clinical cohort found that the ACCESS trial enrolled a more racially and ethnically diverse and socioeconomically disadvantaged population. Trial designs that broaden eligibility could expand access to HCT, highlighting the need for systemic interventions to ensure equity.

Introduction

The use of HLA allele mismatched donors, in the setting of novel graft-vs-host disease (GVHD) prophylaxis approaches, such as posttransplant cyclophosphamide, has substantially and safely expanded access to potentially curative allogeneic hematopoietic cell transplant (HCT).1,2 These approaches have particularly increased access for racially and ethnically diverse patients who are considerably less likely to have HLA allele–matched donors within their families or on national and international donor registries. Disparities in donor availability are compounded by broad structural socioeconomic barriers, including reduced access to clinical trials3 and increased financial toxicity,4 which may continue to exclude certain populations from receiving HCT.

Barriers associated with cancer clinical trial participation are well documented.5 National estimates from 2024 found that approximately 20% of all patients with cancer are eligible to participate in a clinical trial, yet less than 10% participate.5,6 Non-Hispanic White patients were significantly more likely to enroll in clinical trials than African American and Hispanic patients.7 Similar disparities were observed in HCT-specific trials, including those conducted by the national prospective National Institutes of Health–funded clinical trial group the Blood and Marrow Transplant Clinical Trials Network (BMT CTN).8

Research consistently has shown not only underrepresentation of racial and ethnic minority individuals in clinical trials but also individuals with low socioeconomic status, defined in one study as low patient income,9 and those who live in rural areas.10 Barriers are multilevel and include other institutional, health systems, payer, clinician, and community factors.11 Financial toxicity, defined as having substantial objective financial burden from direct and indirect medical costs leading to subjective financial burden, is an individual and interpersonal barrier known to be associated with clinical trial participation.12,13

When certain populations are underrepresented in clinical trials, critical data on treatment efficacy and safety in those groups may be lacking, perpetuating disparities in outcomes. To address these challenges, the NMDP-sponsored, Center for International Blood and Marrow Transplant Research (CIBMTR)–led ACCESS trial14 was designed to evaluate the safety and efficacy of using peripheral blood stem cells from mismatched unrelated donors in adults with high-risk hematologic cancers receiving either myeloablative conditioning (MAC) or reduced-intensity and nonmyeloablative conditioning (RIC/NMA) and posttransplant cyclophosphamide as GVHD prophylaxis. Primary study results demonstrated excellent 1-year overall survival rates and acceptable rates of GVHD and other HCT complications, irrespective of conditioning intensity and level of HLA allele mismatch.15 Recent data from the CIBMTR clinical outcomes registry reported the overall racial and ethnic diversity of adult patients receiving an allogeneic HCT over time, including the years of the ACCESS trial (2021-2023), which included 5% Asian, 8% Black or African American, 15% Hispanic, and 71% non-Hispanic White participants, as well as 1% participants reporting other race and ethnicity.

In this cross-sectional study, we compared the social risks of patients enrolled in the ACCESS trial with a clinical cohort of HCT recipients reported to the CIBMTR registry and patients enrolled in the BMT CTN 1703 trial.16,17 We hypothesized that ACCESS participants would be more racially and ethnically diverse and socially at risk, as measured by neighborhood disadvantage, compared with patients enrolled in BMT CTN 1703 and the CIBMTR Patient-Reported Outcomes Protocol (PRO Protocol).

Methods

Study Design

This cross-sectional study analyzed baseline socioeconomic, social drivers of health, and patient characteristics among 3 patient populations: (1) patients enrolled in the ACCESS clinical trial from 2021 to 2024 with 1-year follow-up PRO data collection (267 participants with 75 in the MAC arm and 192 in the RIC/NMA arm); (2) patients enrolled in the BMT CTN 1703 clinical trial from 2019 to 2021 with 1-year follow-up PRO data collection (420 participants); and (3) patients enrolled in the ongoing CIBMTR PRO Protocol from 2020 to 2025 (506 participants, with 190 in the MAC group and 316 in the RIC/NMA group), which collects a standard set of PROs at clinically relevant time points. The data reported for this analysis were pulled from respective databases in October 2024. Each study protocol was approved by the NMDP Institutional Review Board, and all participants provided written informed consent. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies.18

There was overlap in the centers enrolling in the studies and CIBMTR PRO Protocol: 19 centers enrolled patients in the ACCESS and BMT CTN 1703 trials, 3 enrolled patients in the PRO Protocol and BMT CTN 1703 trial, 2 enrolled patients in both the PRO Protocol and ACCESS trial, and 2 enrolled patients in all 3 studies (eFigure in Supplement 1). Patients enrolled in ACCESS were aged 18 years or older and were undergoing their first mismatched unrelated donor HCT. Eligible diagnoses included acute or chronic leukemia without circulating blasts and less than 5% bone marrow blasts, myelodysplastic syndrome, or lymphoma in remission. Patients with myelofibrosis were not included. Patients enrolled in BMT CTN 1703, a randomized, multicenter trial comparing calcineurin inhibitor and posttransplant cyclophosphamide–based GVHD prophylaxis after HLA allele–matched or 1 antigen mismatch unrelated donor peripheral blood stem cell HCT, had similar inclusion criteria as ACCESS. Patients enrolled in the PRO Protocol were adult allogeneic HCT recipients from centers that allowed CIBMTR to contact their eligible patients for enrollment into the observational PRO Protocol and were included as a convenience sample.

Participants

Participants included adult patients enrolled in the 3 studies who completed a baseline PRO survey. Participants in ACCESS and PRO Protocol were analyzed separately based on conditioning regimen intensity (MAC and RIC/NMA) given the differences in demographics between the 2 patient populations (eg, age, disease). All patients in BMT CTN 1703 received RIC/NMA per protocol design.

Measures and Outcomes

Race and ethnicity were reported by the participating centers for all studies and supplemented with self-reported data if missing from centers participating in ACCESS and PRO Protocol. The categories used for this analysis were Asian, Black or African American, Hispanic or Latino, non-Hispanic White, or other (American Indian or Alaska Native, Native Hawaiian or Pacific Islander, or multiracial). Social drivers of health were operationalized using the Centers for Disease Control and Prevention–developed Social Vulnerability Index (SVI), a place-based index designed to identify and quantify communities experiencing social disadvantage.19 The SVI, used widely in cancer care research,20 includes 16 US Census variables from the American Community Survey to identify communities that are more disadvantaged. Patient zip codes are used to develop a score from 0 to 1, where higher values are associated with greater social disadvantage. The SVI includes an overall and 4 subscale (socioeconomic status, household characteristics, racial and ethnic minority status, housing type and transportation) scores and is updated regularly to ensure accuracy. Given that the BMT CTN 1703 participants completed their baseline surveys in 2019 to 2021, we conducted a sensitivity analysis using SVI data from 2020 to see whether there were significant differences. All results remained consistent. Therefore, the more recent SVI scores (2022) were used for analysis.

Financial toxicity was assessed among ACCESS and PRO Protocol participants using the Comprehensive Score for Financial Toxicity (COST), version 2 measure, which captures a patient’s material and psychosocial financial hardship (scale of 0-44, with higher scores indicating better financial well-being). The COST measure is a 12-item, 5-point Likert scale questionnaire that assesses the stress and anxiety of health-cost financial burdens and material impacts.12 To assess distance to a transplant center, geodetic distance in miles was used by calculating the distance between the patient and transplant center zip codes. The BMT CTN 1703 did not collect COST and Functional Assessment of Chronic Illness Therapy or socioeconomic status information (eg, educational attainment, household income); therefore, those participants are not part of the socioeconomic comparison.

Statistical Analysis

Statistical analyses were performed in accordance with the ACCESS trial PRO statistical analysis plan for the protocol (Supplement 2). Baseline patient characteristics, including socioeconomic status, SVI, financial toxicity, and clinical characteristics were compared. Percentages were calculated using available data; missing values were reported separately and excluded from testing. Wilcoxon rank sum and Fisher exact tests were used to determine statistically significant differences between groups, with P < .05 set as the threshold. The statistical analyses were conducted using SAS, version 9.4 (SAS Institute Inc) and R, version 4.4.3 (R Foundation for Statistical Computing).

Results

Of the patients enrolled in each cohort, baseline surveys were completed by 208 in the ACCESS trial (60 of 75 in the MAC group [80.0% response rate] and 148 of 192 in the RIC/NMA group [77.1% response rate]; median [range] age at transplant, 62.3 [20.4-78.9] years; 100 female [48.1%] and 108 male [51.9%]; 90 participants [43.2%] reporting being unable to work due to illness or disability), 122 patients in the PRO Protocol study (36 of 190 in the MAC group [18.9% response rate] and 86 of 316 in the RIC/NMA group [27.2% response rate]; median [range] age at transplant, 63.9 [21.1-78.0] years; 55 female [45.1%] and 67 male [54.9%]; 42 of 100 participants [42.0%] reporting a household income of ≥$100 000), and 342 of 420 patients from the BMT CTN 1703 trial (81.4% response rate; median [range] age at transplant, 66.9 [20.7-78.6] years; 124 female [36.3%] and 218 male [63.7%]; 237 of 305 participants [77.7%] were married) (Table). Participants in ACCESS were significantly more racially and ethnically diverse (15 Asian [7.2%], 25 Black or African American [12.1%], 46 Hispanic or Latino [22.2%], and 110 White [53.1%] participants, as well as 11 participants reporting other [5.3%] race and ethnicity) compared with those in PRO Protocol (4 Asian [3.3%], 2 Black or African American [1.6%], 8 Hispanic or Latino [6.6%], and 104 White [85.2%] participants, as well as 4 participants reporting other [3.3%] race and ethnicity) and BMT CTN 1703 (10 Asian [3.0%], 0 Black or African American, 16 Hispanic or Latino [4.8%], and 302 White [91.0%] participants, as well as 4 participants reporting other [1.2%] race and ethnicity) (P < .001). Other significantly different characteristics included insurance type, with 103 ACCESS participants (49.5%) with government-sponsored insurance compared with 58 PRO Protocol participants (47.5%) (P = .009) and 177 BMT CTN 1703 participants (51.8%) (P < .001). The ACCESS trial had a larger proportion of patients with Medicaid (36 [18.1%]) compared with PRO Protocol (6.7%) and BMT CTN 1703 (5.1%). A more detailed insurance breakdown is provided in the eTable in Supplement 1. In both the ACCESS trial and PRO Protocol study, participants in the MAC group were younger and had fewer comorbidities (Table).

Table. Patient Characteristics for the ACCESS Trial, CIBMTR PRO Protocol, and BMT CTN 1703 Trial.

Characteristic MAC RIC/NMA Total
ACCESS (n = 60; 18 centers) PRO Protocol (n = 36; 8 centers) P value ACCESS (n = 148; 30 centers) PRO Protocol (n = 86; 10 centers) P value ACCESS vs PRO Protocol BMT CTN 1703 (n = 342; 36 centers) P value ACCESS vs BMT CTN 1703 ACCESS (n = 208; 33 centers) PRO (n = 122; 12 centers) P value
Demographics, No. (%)
Age at transplant, median (range), y 50.2 (20.4-65.6) 47.0 (21.1-68.1) .58a 65.0 (22.9-78.9) 66.5 (29.4-78.0) .21a 66.9 (20.7-78.6) .009a 62.3 (20.4-78.9) 63.8 (21.1-78.0) .29a
Age at transplant, y
18-44 25 (41.7) 16 (44.4) .25b 15 (10.1) 7 (8.1) .34b 11 (3.2) <.001b 40 (19.2) 23 (18.9) .29b
45-64 34 (56.7) 17 (47.2) 58 (39.2) 26 (30.2) 122 (35.7) 92 (44.2) 43 (35.2)
65-74 1 (1.7) 3 (8.3) 65 (43.9) 43 (50.0) 196 (57.3) 66 (31.7) 46 (37.7)
≥75 0 0 10 (6.8) 10 (11.6) 13 (3.8) 10 (4.8) 10 (8.2)
Sex
Female 22 (36.7) 18 (50.0) .21b 78 (52.7) 37 (43.0) .18b 124 (36.3) <.001b 100 (48.1) 55 (45.1) .65b
Male 38 (63.3) 18 (50.0) 70 (47.3) 49 (57.0) 218 (63.7) 108 (51.9) 67 (54.9)
Race and ethnicity
Asian 5 (8.3) 3 (8.3) <.001b 10 (6.8) 1 (1.2) <.001b 10 (2.9) <.001b 15 (7.2) 4 (3.3) <.001b
Black or African American 7 (11.7) 1 (2.8) 18 (12.2) 1 (1.2) 0 25 (12.0) 2 (1.6)
Hispanic or Latino 24 (40.0) 3 (8.3) 22 (14.9) 5 (5.8) 16 (4.7) 46 (22.1) 8 (6.6)
Non-Hispanic White 21 (35.0) 27 (75.0) 89 (60.1) 77 (89.5) 302 (88.3) 110 (52.9) 104 (85.2)
Otherc 3 (5.0) 2 (5.6) 8 (5.4) 2 (2.3) 4 (1.2) 11 (5.3) 4 (3.3)
Unknown 0 0 NA 0 0 NA 10 (2.9) NA 0 0 NA
Not reported 0 0 NA 1 (0.7) 0 NA 0 NA 1 (0.5) 0 NA
Socioeconomic, No. (%)
Household annual income, $d
<40 000 11 (24.4) 6 (19) .47b 25 (24.0) 8 (11.6) .02b 7 (38.9) .03b 36 (24.2) 14 (14.0) .16b
40 000-79 999 11 (24.4) 12 (39) 34 (32.7) 16 (23.2) 2 (11.1) 45 (30.2) 28 (28.0)
80 000-99 999 4 (8.9) 4 (13) 17 (16.3) 12 (17.4) 7 (38.9) 21 (14.1) 16 (16.0)
≥100 000 19 (42.2) 9 (29) 28 (26.9) 33 (47.8) 2 (11.1) 47 (31.5) 42 (42.0)
Declined or unknown 11 4 NA 24 6 NA 288 NA 35 10 NA
Not reported 4 1 NA 20 11 NA 36 NA 24 12 NA
Job status
Currently employed (full or part time) 10 (17.5) 8 (22.9) 0.92b 17 (12.1) 18 (21.2) 0.13b 0 NA 27 (13.7) 26 (21.7) 0.16b
Retired 5 (8.8) 3 (8.6) 66 (47.1) 44 (51.8) 0 71 (36.0) 47 (39.2)
Unable to work due to illness or disability 39 (68.4) 23 (65.7) 51 (36.4) 21 (24.7) 0 90 (45.7) 44 (36.7)
Other unemployede 3 (5,3) 1. (2.9) 6 (4.3) 2 (2.4) 0 9 (4.6) 3 (2.5
Not reported 3 1 NA 8 1 NA 0 NA 11 2 NA
Health insuranced
Medicaid 12 (21.8) 5 (13.9) .81b 24 (16.8) 3 (3.6) .001b 16 (5.1) <.001b 36 (18.2) 8 (6.7) .009b
Medicare 4 (7.3) 3 (8.3) 63 (44.1) 47 (56.0) 161 (51.3) 67 (33.8) 50 (41.7)
Private 32 (58.2) 22 (61.1) 44 (30.8) 33 (39.3) 129 (41.1) 76 (38.4) 55 (45.8)
Otherc 7 (12.7) 6 (16.7) 12 (8.4) 1 (1.2) 8 (2.5) 19 (9.6) 7 (5.8)
Not reported 5 0 NA 5 2 NA 28 NA 10 2 NA
Relationship statusd
Married or domestic partnership 41 (69.5) 16 (51.6) .11b 103 (70.5) 54 (78.3) .25b 237 (77.7) .10b 144 (70.2) 70 (70.0) >.99b
Otherf 18 (30.5) 15 (48.4) 43 (29.5) 15 (21.7) 68 (22.3) 61 (29.8) 30 (30.0)
Not reported 1 5 NA 2 17 NA 37 NA 3 22 NA
Highest education leveld
High school or less 18 (31.0) 6 (17.1) .31b 41 (29.7) 6 (7.1) <.001b 0 NA 59 (30.1) 12 (10.0) <.001b
Some college or associate’s degree 28 (48.3) 22 (62.9) 75 (54.3) 51 (60.0) 0 103 (52.6) 73 (60.8)
Postcollege degree 12 (20.7) 7 (20.0) 22 (15.9) 28 (32.9) 0 34 (17.3) 35 (29.2)
Not reported 2 1 NA 10 1 NA 342 NA 12 2 NA
Census regiond
Northeast 6 (10.0) 8 (22.2) .003b 44 (29.7) 15 (17.4) <.001b 59 (17.4) <.001b 50 (24.0) 23 (18.9) <.001b
Midwest 9 (15.0) 12 (33.3) 27 (18.2) 13 (15.1) 125 (36.8) 36 (17.3) 25 (20.5)
South 23 (38.3) 13 (36.1) 45 (30.4) 55 (64.0) 91 (26.8) 68 (32.7) 68 (55.7)
West 22 (36.7) 3 (8.3) 32 (21.6) 3 (3.5) 65 (19.1) 54 (26.0) 6 (4.9)
Not reported 0 0 NA 0 0 NA 2 NA 0 0 NA
Geodetic distance to transplant center, median (IQR), miles 24 (11-42) 29 (11-70) .42a 28 (14-75) 49 (21-104) .008a 47 (16-96) .03a 27 (13-69) 44 (18-95) .01a
Financial toxicity
COST score, median (range) 23 (0-44) 26 (0-40) .58a 27 (0-44) 28 (0-44) .93a NE NA 26 (0-44) 28 (0-44) .73a
COST graded
0 (≥26; No financial toxicity) 24 (41.4) 18 (51.4) .60b 79 (57.2) 47 (56.0) .62b 0 NA 103 (52.6) 65 (54.6) .80b
1 (14-25) 18 (31.0) 7 (20.0) 39 (28.3) 28 (33.3) 0 57 (29.1) 35 (29.4)
2 (<14) 15 (25.9) 9 (25.7) 18 (13.0) 7 (8.3) 0 33 (16.8) 16 (13.4)
3 (0; Severe financial toxicity) 1 (1.7) 1 (2.9) 2 (1.4) 2 (2.4) 0 3 (1.5) 3 (2.5)
Not reported 2 1 NA 10 2 NA 342 NA 12 3 NA
SVI 2022
Overall SVI, median (range) 0.72 (0.01-0.97) 0.61 (0.16-0.78) .007a 0.57 (0.02-1.00) 0.63 (0.13-0.98) .26a 0.49 (0-1.00) .06a 0.59 (0.01-1.00) 0.63 (0.13-0.98) .65a
SVI categoriesd
Low (≤0.25; least disadvantaged) 4 (6.7) 2 (5.6) .006b 24 (16.3) 5 (5.8) .003b 81 (23.8) .04b 28 (13.5) 7 (5.7) <.001b
Low-medium (>0.25 to ≤0.50) 12 (20.0) 13 (36.1) 42 (28.6) 22 (25.6) 90 (26.5) 54 (26.1) 35 (28.7)
Medium-high (>0.50 to ≤0.75) 16 (26.7) 16 (44.4) 33 (22.4) 38 (44.2) 94 (27.6) 49 (23.7) 54 (44.3)
High (>0.75 to 1.00; most disadvantaged) 28 (46.7) 5 (13.9) 48 (32.7) 21 (24.4) 75 (22.1) 76 (36.7) 26 (21.3)
Not reported 0 0 NA 1 0 NA 2 NA 1 0 NA
Socioeconomic status, median (range) 0.67 (0.02-0.96) 0.52 (0.12-0.73) .007a 0.45 (0.02-0.98) 0.65 (0.07-0.99) .12a 0.42 (0.01-0.98) .09a 0.54 (0.02-0.98) 0.59 (0.07-0.99) .91a
Socioeconomic status, No. (%)d
Low (≤0.25; least disadvantaged) 9 (15.0) 7 (19.4) <.001b 39 (26.5) 14 (16.3) <.001b 108 (31.8) .07b 48 (23.2) 21 (17.2) <.001b
Low-medium (>0.25 to ≤0.50) 9 (15.0) 10 (27.8) 39 (26.5) 16 (18.6) 87 (25.6) 48 (23.2) 26 (21.3)
Medium-high (>0.50 to ≤0.75) 17 (28.3) 19 (52.8) 27 (18.4) 43 (50.0) 82 (24.1) 44 (21.3) 62 (50.8)
High (>0.75 to 1.00; most disadvantaged) 25 (41.7) 0 42 (28.6) 13 (15.1) 63 (18.5) 67 (32.4) 13 (10.7)
Not reported 0 0 NA 1 0 NA 2 NA 1 0 NA
Household characteristics, median (range) 0.44 (0.03-0.84) 0.49 (0.02-0.78) .29a 0.36 (0.02-0.98) 0.52 (0.05-0.92) <.001a 0.39 (0.02-0.98) .18a 0.38 (0.02-0.98) 0.49 (0.02-0.92) <.001a
Household characteristics, No. (%)d
Low (≤0.25; least disadvantaged) 17 (28.3) 8 (22.2) .007b 56 (38.1) 17 (19.8) <.001b 123 (36.2) .006b 73 (35.3) 25 (20.5) <.001b
Low-medium (>0.25 to ≤0.50) 26 (43.3) 12 (33.3) 55 (37.4) 25 (29.1) 84 (24.7) 81 (39.1) 37 (30.3)
Medium-high (>0.50 to ≤0.75) 6 (10.0) 14 (38.9) 21 (14.3) 27 (31.4) 86 (25.3) 27 (13.0) 41 (33.6)
High (>0.75 to 1.00; most disadvantaged) 11 (18.3) 2 (5.6) 15 (10.2) 17 (19.8) 47 (13.8) 26 (12.6) 19 (15.6)
Not reported 0 0 NA 1 0 NA 2 NA 1 0 NA
Racial and ethnic minority status, median (range) 0.89 (0.05-0.99) 0.66 (0.06-0.94) <.001a 0.76 (0.11-1.00) 0.67 (0.12-1.00) .004a 0.68 (0.02-1.00) <.001a 0.81 (0.05-1.00) 0.67 (0.06-1.00) <.001a
Racial and ethnic minority status, 2022, No. (%)d
Low (≤0.25; least disadvantaged) 3 (5.0) 1 (2.8) .002b 7 (4.8) 8 (9.3) .03b 31 (9.1) .004b 10 (4.8) 9 (7.4) <.001b
Low-medium (>0.25 to ≤0.50) 2 (3.3) 7 (19.4) 17 (11.5) 14 (16.3) 77 (22.6) 19 (9.2) 21 (17.2)
Medium-high (>0.50 to ≤0.75) 12 (20.0) 14 (38.9) 47 (32.0) 36 (41.9) 93 (27.4) 59 (28.5) 50 (41.0)
High (>0.75 to 1.00; most disadvantaged) 43 (71.7) 14 (38.9) 76 (51.7) 28 (32.6) 139 (40.9) 119 (57.5) 42 (34.4)
Not reported 0 0 NA 1 0 NA 2 NA 1 0 NA
Housing type and transportation, median (range) 0.81 (0.04-0.99) 0.63 (0.22-0.98) .005a 0.71 (0.03-0.98) 0.67 (0.24-0.92) .24a 0.62 (0.02-1.00) .002a 0.72 (0.03-0.99) 0.67 (0.22-0.98) .01a
Housing type and transportation, No. (%)d
Low (≤0.25; least disadvantaged) 4 (6.7) 2 (5.6) .10b 16 (10.8) 1 (1.2) .004b 62 (18.2) .003b 20 (9.7) 3 (2.5) <.001b
Low-medium (>0.25 to ≤0.50) 8 (13.3) 8 (22.2) 23 (15.6) 20 (23.3) 68 (20.0) 31 (15.0) 28 (23.0)
Medium-high (>0.50 to ≤0.75) 15 (25.0) 15 (41.7) 44 (29.9) 37 (43.0) 120 (35.3) 59 (28.5) 52 (42.6)
High (>0.75 to 1.00; most disadvantaged) 33 (55.0) 11 (30.6) 64 (43.5) 28 (32.6) 90 (26.5) 97 (46.9) 39 (32.0)
Not reported 0 0 NA 1 0 NA 2 NA 1 0 NA
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Abbreviations: CIBMTR PRO Protocol, Center for International Blood and Marrow Transplant Research Patient-Reported Outcomes Protocol; COST, Comprehensive Score for Financial Toxicity; MAC, myeloablative conditioning; NA, not applicable; RIC/NMA, reduced-intensity and nonmyeloablative conditioning; SVI, Social Vulnerability Index.

a

Hypothesis testing: Wilcoxon rank sum test.

b

Hypothesis testing: Fisher exact test.

c

Included American Indian or Alaska Native, Native Hawaiian or Pacific Islander, and multiracial.

d

Percentages calculated from participants who answered the question (ie, excluded declined or unknown or not reported).

e

Included unemployed due to other reasons or student.

f

Included never married, separated, divorced, widowed, or other.

Socioeconomic Status

There were significant differences in educational attainment between the PRO Protocol and ACCESS RIC/NMA groups, with a larger portion of PRO Protocol participants having some college or an associate’s degree (73 [59.8%] vs 103 ACCESS participants [49.5%]; P < .001) and postcollege education (35 [29.2%] vs 34 ACCESS participants [17.3%]; P < .001) (Table). There were no significant differences in employment status or household income between the ACCESS and PRO Protocol MAC groups but were noted in the RIC/NMA group in the ACCESS and PRO Protocol studies. For ACCESS, 25 participants (24.0%) had an annual household income of less than $40 000 compared with 8 (11.6%) in PRO Protocol and 7 (38.9%) in BMT CTN 1703, and 28 participants in ACCESS (26.9%) had a household income of at least $100 000 compared with 33 (47.8%) in PRO Protocol and 2 (11.1%) in BMT CTN 1703.

SVI

Participants in the ACCESS MAC group were from more socially disadvantaged communities, with a median SVI score of 0.72 (range, 0.01-0.97) (Figure 1; Table). Participants in the PRO Protocol had a median SVI score of 0.61 (range, 0.16-0.78) in the MAC group and 0.63 (range, 0.13-0.98) in the RIC/NMA group. The ACCESS MAC group had significantly more social disadvantage compared with the PRO Protocol MAC group (P = .007).

Figure 1. Box Plots of Social Vulnerability Index by Study and Conditioning Regimen.

Figure 1.

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The lower and upper edges of each box represent the 25th and 75th percentiles, respectively, with the horizontal line indicating the median. Whiskers extend to the most extreme values within 1.5 times the IQR from the quartiles. MAC indicates myeloablative conditioning; PRO, Center for International Blood and Marrow Transplant Research Patient-Reported Outcomes Protocol; RIC/NMA, reduced intensity and nonmyeloablative conditioning.

The SVI subscale scores were significantly higher for the ACCESS compared with the PRO Protocol MAC group for socioeconomic status (median [range], 0.67 [0.02-0.96] vs 0.52 [0.12-0.73]; P = .007), racial and ethnic minority status (median [range], 0.89 [0.05-0.99] vs 0.66 [0.06-0.94]; P < .001), and housing type and transportation (median [range], 0.81 [0.04-0.99] vs 0.63 [0.22-0.98]; P = .005), indicating that these participants were more commonly living below the 150% federal poverty level, unemployed, experiencing housing cost burden (socioeconomic status SVI subscale), and living in communities in which other racial and ethnic minority groups lived (racial and ethnic minority SVI subscale). Among the RIC/NMA groups, ACCESS had the highest percentage of participants living in communities in the most disadvantaged quartile (48 [32.7%]) compared with PRO Protocol (21 [24.4%]) and BMT CTN 1703 (75 [22.1%]) participants.

Financial Toxicity

Overall, 57 ACCESS participants (29.5%) reported grade 1 (mild) financial toxicity, and 36 (18.7%) reported grade 2 and 3 (moderate to severe) financial toxicity. In comparison, 35 PRO Protocol participants (29.4%) reported grade 1 and 19 (16.0%) reported grade 2 or 3 financial toxicity. Participants in ACCESS with Medicaid insurance reported a median COST score of 19 (range, 12-31), indicating mild financial toxicity, compared with patients with Medicare (median, 30; range, 23-35) or private insurance (median, 26; range, 17-32), for which both reported little to no financial toxicity (Figure 2). In the MAC groups, 16 ACCESS participants (27.6%) and 10 PRO Protocol participants (25.7%) reported moderate to severe financial toxicity (ie, grades 2-3 with a score <14). However, for the RIC/NMA group, 20 ACCESS participants (14.5%) and 9 PRO Protocol participants (10.7%) reported moderate to severe financial toxicity (P = .62).

Figure 2. Box Plots of Comprehensive Score for Financial Toxicity (COST) by Insurance Status for ACCESS and PRO Protocol Participants, by Conditioning Regimen.

Figure 2.

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The lower and upper edges of each box represent the 25th and 75th percentiles, respectively, with the horizontal line indicating the median. Whiskers extend to the most extreme values within 1.5 times the IQR from the quartiles; points beyond this range are shown as individual outliers. Background color bands denote levels of financial toxicity: green (score 0, severe financial toxicity), blue (scores 1-13, moderate financial toxicity), white (scores 14-25, mild financial toxicity), and gray (scores 26-44, better financial well-being). MAC indicates myeloablative conditioning; PRO, Center for International Blood and Marrow Transplant Research Patient-Reported Outcomes Protocol; RIC/NMA, reduced intensity or nonmyeloablative conditioning.

Distance to Transplant Center

Participants in the ACCESS MAC group had a median of 24 miles (IQR, 11-42 miles) travel distance to a transplant center, and RIC/NMA group participants had a median of 28 miles (IQR, 14-75 miles). Participants in BMT CTN 1703 had the highest median distance of 47 miles (IQR, 16-96 miles). Participants in the PRO Protocol had a median distance of 49 miles (IQR, 21-104 miles). No significant differences in median distance to a transplant center were noted between the MAC groups. For the RIC/NMA groups, ACCESS participants lived significantly closer to centers compared with those in the PRO Protocol (P < .001), which was also significantly closer than for BMT CTN 1703 participants (P = .03). Though the proportion of patients in different parts of the country varied, the overall distribution of patients throughout the US was similar for all 3 patient cohorts (Figure 3).

Figure 3. Heat Map of Social Vulnerability Index (SVI) in the US and Location of Patient Home Zip Code, by Study.

Figure 3.

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Each map displays the quartile of the SVI by US Census tract. Lighter shading indicates more social advantage, and darker shading indicates more social disadvantage. NA indicates not available; PRO, Center for International Blood and Marrow Transplant Research Patient-Reported Outcomes Protocol. Images rendered using Leaflet (ESRI).

Discussion

This cross-sectional study involving a secondary analysis of baseline socioeconomic and social disadvantage characteristics across 2 large HCT clinical trials and a national clinical cohort revealed significant differences in enrolled patient populations. Compared with BMT CTN 1703 and PRO Protocol participants, ACCESS participants were not only more racially and ethnically diverse but also had more social disadvantage, with lower household incomes and educational attainment. Participants in ACCESS were also more racially and ethnically diverse compared with those registered in the full CIBMTR registry database.

Barriers to clinical trial participation exist at the structural (health care systems, delivery, financing, and policy), institutional (resource availability, referral practices, payer), and patient (social isolation, exposure to violence, health literacy) levels.11 As a result, disparity in enrollment of patients from underrepresented and underresourced communities persist in clinical trial research. Our findings show that barriers associated with donor availability in racially and ethnically underrepresented groups might be overcome by broadening the donor types that can be selected for patients enrolling in clinical trials (as might have been expected) through technological advancements, but surprisingly, this also increases access and clinical trial participation among patients from more socially disadvantaged communities and with lower income households.

The SVI was significantly higher among ACCESS participants, suggesting that these individuals were more likely to reside in areas with limited access to health care, transportation, and economic resources. High SVI scores are associated with poorer health outcomes and reduced health care use,21,22 making the SVI an important metric for understanding barriers to HCT access. Enrollment of patients with substantially more social disadvantages might reflect physicians’ willingness to enroll patients receiving novel therapies in a clinical trial, which typically comes with more structured and standardized oversight, funding, and resources, rather than offering a similar patient such an approach as standard of care. Future research should identify and bridge the gap between clinical trial and standard-of-care patient enrollment.

Participants in the ACCESS trial seemed to be clustered close to transplant centers compared with BMT CTN 1703 and PRO Protocol participants (Figure 3). When undergoing HCT, patients (and caregivers) typically need to live (or relocate to) within a short distance of the transplant center. This clustering may be a reflection of more racial and ethnic diversity in urban areas where many transplant centers are located or may reflect the constraints on underserved patients, often due to lack of resources and ability to travel far distances, limiting what treatment options are available or offered to them close to their home. These geographic findings support the value in broadening the availability of protocols with similar enrollment criteria to all centers.

Importantly, the increased social disadvantage observed in ACCESS participants was not solely associated with racial and ethnic diversity, suggesting that socioeconomic disadvantage is a distinct and critical factor influencing trial participation and access to HCT. Prior research has shown that poverty is a significant predictor of whether patients receive unrelated donor transplants, with those living below the federal poverty level significantly less likely to undergo transplant.23 Our findings, though specific to patients who have received a transplant, align with this literature and emphasize the need for systemic interventions to address these disparities.

The SVI was significantly different between ACCESS and PRO Protocol participants, but financial toxicity was not. This difference may be due to the 2 measures capturing different levels of access barriers, one at the personal and interpersonal level (financial toxicity) and the other at the neighborhood and social level (SVI).12,13 The COST measure specifically focuses on psychosocial and material constructs of financial toxicity. Therefore, patients may be reporting less stress and anxiety about their financial situation because they are well informed of the costs of HCT. In contrast, SVI captures the social and community-level factors that affect a patient’s resource availability and social and financial capital.24 Results from this study suggest that the ACCESS trial could overcome some neighborhood and structural barriers; however, a further exploration and understanding of these differences is essential for designing future trials and clinical programs that are both inclusive and equitable. The study results that showed differences in financial toxicity by insurance type highlight the intersectional influences of socioeconomic disadvantage and the potential compounding disadvantages patients may experience. Interventions such as transportation assistance, housing support, and financial counseling may help mitigate the barriers faced by patients with social disadvantages.

The ACCESS trial demonstrated clear progress toward greater access to treatment for racial and ethnic minority and socially disadvantaged patients, but there is still progress to be made. Ideally, every patient who needs a transplant would have access to a suitable donor. Realization of this goal could be achieved via dissemination and implementation strategies so that methods used in the ACCESS trial become widely adopted at more transplant centers, ensuring that patient financial navigators are made available to patients experiencing financial toxicity and increasing access to treatment centers in every state. The NMDP-sponsored CIBMTR trial ACCELERATE, is an ongoing platform trial assessing novel drug combinations designed to make transplant safer and will target activation at nearly double the number of sites that enrolled in ACCESS.25

Limitations

This study had several limitations. The trials analyzed were conducted during different periods (including the COVID-19 pandemic) and had differing trial designs, eligibility criteria, and data collection methods, which may introduce the potential for confounding. This heterogeneity may limit direct comparisons among the populations. The PRO Protocol is a convenience sampling of centers that agreed to allow us to reach out to their patients, therefore limiting the generalizability of these patients as a comparison group. Furthermore, missing data, either known (ie, BMT CTN 1703 did not collect the COST measure) or unknown (ie, patients not reporting household income in the PRO Protocol) may limit the robustness of the findings. Provision of support and resources to patients and caregivers may also improve access but was not assessed in this study. Finally, our study only addressed patients who received a transplant; thus, further research is necessary to understand barriers that prevent a patient from progressing through the multiple steps required prior to receiving this complex therapy. Despite these limitations, the consistency of findings across several multilevel factors, including individual- and community-level barriers to clinical trials, strengthens the validity of our conclusions and should be considered as hypothesis-generating data.

Conclusions

This cross-sectional study of trial participants with a clinical comparison study found that a trial that expanded the use of alternative donor sources, such as mismatched unrelated donors, for HCT had increased participation by racial and ethnic minority patients as well as a more socially disadvantaged population. Future research should explore targeted strategies to reduce barriers to HCT for socially disadvantaged populations, including policy-level interventions and community-based outreach. Moreover, incorporating social drivers of health into trial design and eligibility criteria should be standardized to improve the generalizability of findings and ensure that new therapies are effective across diverse populations. Finally, broadening the availability of novel therapies and donor types and modifying standard-of-care approaches could provide better patient access to achieve an ideal state in which every patient who needs a transplant will have access to a suitable donor.

Supplement 1.

eFigure. Venn Diagram of the Overlap of Centers Participating in ACCESS, BMT CTN 1703, CIBMTR PRO Protocol

eTable. Detailed Insurance Status by Study and Conditioning Regimen

jamanetwopen-e2610839-s001.pdf (285.7KB, pdf)
Supplement 2.

ACCESS Trial Protocol and Statistical Analysis Plan: PRO Protocol

jamanetwopen-e2610839-s002.pdf (2.6MB, pdf)
Supplement 3.

Data Sharing Statement

jamanetwopen-e2610839-s003.pdf (12.7KB, pdf)

References

  • 1.Chowdhury AS, Maiers M, Spellman SR, Deshpande T, Bolon YT, Devine SM. Existence of HLA-mismatched unrelated donors closes the gap in donor availability regardless of recipient ancestry. Transplant Cell Ther. 2023;29(11):686.e1-686.e8. doi: 10.1016/j.jtct.2023.08.014 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Shaffer BC, Gooptu M, DeFor TE, et al. Post-transplant cyclophosphamide-based graft-versus-host disease prophylaxis attenuates disparity in outcomes between use of matched or mismatched unrelated donors. J Clin Oncol. 2024;42(28):3277-3286. doi: 10.1200/JCO.24.00184 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Pittell H, Calip GS, Pierre A, et al. Racial and ethnic inequities in US oncology clinical trial participation from 2017 to 2022. JAMA Netw Open. 2023;6(7):e2322515. doi: 10.1001/jamanetworkopen.2023.22515 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Hammarlund N, Jacobs M. Racial and ethnic disparities in financial toxicity among cancer survivors: implications for equity in survivorship care. J Cancer Surviv. Published online June 5, 2025. doi: 10.1007/s11764-025-01817-1 [DOI] [PubMed] [Google Scholar]
  • 5.Unger JM, Vaidya R, Hershman DL, Minasian LM, Fleury ME. Systematic review and meta-analysis of the magnitude of structural, clinical, and physician and patient barriers to cancer clinical trial participation. J Natl Cancer Inst. 2019;111(3):245-255. doi: 10.1093/jnci/djy221 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Unger JM, Shulman LN, Facktor MA, Nelson H, Fleury ME. National estimates of the participation of patients with cancer in clinical research studies based on commission on cancer accreditation data. J Clin Oncol. 2024;42(18):2139-2148. doi: 10.1200/JCO.23.01030 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Duma N, Aguilera JV, Paludo J, et al. Representation of minorities and women in oncology clinical trials: review of the past 14 years. J Oncol Pract. 2018;14(1):e1-e10. doi: 10.1200/JOP.2017.025288 [DOI] [PubMed] [Google Scholar]
  • 8.Kaur M, Horowitz MM, Mendizabal A, et al. Representativeness of Blood and Marrow Transplant Clinical Trials Network (BMT CTN) trial participants. Transplant Cell Ther. 2025;31(1):49-57. doi: 10.1016/j.jtct.2024.10.014 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Unger JM, Gralow JR, Albain KS, Ramsey SD, Hershman DL. Patient income level and cancer clinical trial participation: a prospective survey study. JAMA Oncol. 2016;2(1):137-139. doi: 10.1001/jamaoncol.2015.3924 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Yabroff KR, Han X, Zhao J, Nogueira L, Jemal A. Rural cancer disparities in the United States: a multilevel framework to improve access to care and patient outcomes. JCO Oncol Pract. 2020;16(7):409-413. doi: 10.1200/OP.20.00352 [DOI] [PubMed] [Google Scholar]
  • 11.Yusuf RA, Preussler JM, Meyer CL, et al. Reducing barriers of access and care related to hematopoietic cell transplantation and cellular therapy: the mission-driven role of the national marrow donor program. Best Pract Res Clin Haematol. 2023;36(2):101480. doi: 10.1016/j.beha.2023.101480 [DOI] [PubMed] [Google Scholar]
  • 12.Witte J, Mehlis K, Surmann B, et al. Methods for measuring financial toxicity after cancer diagnosis and treatment: a systematic review and its implications. Ann Oncol. 2019;30(7):1061-1070. doi: 10.1093/annonc/mdz140 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Gharzai LA, Ryan KA, Szczygiel L, et al. Financial toxicity during breast cancer treatment: a qualitative analysis to inform strategies for mitigation. JCO Oncol Pract. 2021;17(10):e1413-e1423. doi: 10.1200/OP.21.00182 [DOI] [PubMed] [Google Scholar]
  • 14.HLA-mismatched unrelated donor hematopoietic cell transplantation with post-transplantation cyclophosphamide (ACCESS). ClinicalTrials.gov identifier: NCT04904588. Updated March 18, 2026. Accessed March 30, 2026. https://clinicaltrials.gov/study/NCT04904588
  • 15.Al Malki MM, Bo-Subait S, Logan B, et al. Post-transplant cyclophosphamide-based graft-versus-host disease prophylaxis after mismatched unrelated donor peripheral blood stem cell transplantation. J Clin Oncol. 2025;43(25):2772-2781. doi: 10.1200/JCO-25-00856 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Bolaños-Meade J, Hamadani M, Wu J, et al. ; BMT CTN 1703 Investigators . Post-transplantation cyclophosphamide-based graft-versus-host disease prophylaxis. N Engl J Med. 2023;388(25):2338-2348. doi: 10.1056/NEJMoa2215943 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.TAC/MTX vs. TAC/MMF/PTCY for prevention of graft-versus-host disease and microbiome and immune reconstitution study (BMT CTN 1703/1801) (1703/1801). ClinicalTrials.gov identifier: NCT03959241. Updated April 4, 2024. Accessed March 30, 2026. https://clinicaltrials.gov/study/NCT03959241
  • 18.Vandenbroucke JP, von Elm E, Altman DG, et al. ; STROBE Initiative . Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. Ann Intern Med. 2007;147(8):W163-W194. doi: 10.1371/journal.pmed.0040297 [DOI] [PubMed] [Google Scholar]
  • 19.Flanagan BE, Gregory EW, Hallisey EJ, Heitgerd JL, Lewis B. A social vulnerability index for disaster management. J Homel Secur Emerg Manag. 2011;8(1):1792. doi: 10.2202/1547-7355.1792 [DOI] [Google Scholar]
  • 20.Tran T, Rousseau MA, Farris DP, Bauer C, Nelson KC, Doan HQ. The social vulnerability index as a risk stratification tool for health disparity research in cancer patients: a scoping review. Cancer Causes Control. 2023;34(5):407-420. doi: 10.1007/s10552-023-01683-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Herring J, Park YH, Luo Q, Vichare A, Erikson C, Pittman P. Medicaid primary care utilization and area-level social vulnerability. JAMA Health Forum. 2025;6(9):e253020. doi: 10.1001/jamahealthforum.2025.3020 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Higginbotham JK, Segovia LM, Rohm KL, Anderson CM, Breitenstein SM. Social vulnerability index and health outcomes in the United States: a systematic review. Fam Community Health. 2025;48(2):81-96. doi: 10.1097/FCH.0000000000000421 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Paulson K, Brazauskas R, Khera N, et al. Inferior access to allogeneic transplant in disadvantaged populations: a Center for International Blood and Marrow Transplant research analysis. Biol Blood Marrow Transplant. 2019;25(10):2086-2090. doi: 10.1016/j.bbmt.2019.06.012 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Spielman SE, Tuccillo J, Foch DC, et al. Evaluating social vulnerability indicators: criteria and their application to the Social Vulnerability Index. Nat Hazard. 2020;100:417-436. doi: 10.1007/s11069-019-03820-z [DOI] [Google Scholar]
  • 25.A platform protocol to investigate post-transplant cyclophosphamide-based graft-versus-host disease prophylaxis in patients with hematologic malignancies undergoing mismatched unrelated donor peripheral blood stem cell transplantation (ACCELERATE). ClinicalTrials.gov identifier: NCT06859424. Accessed March 30, 2026. https://www.clinicaltrials.gov/study/NCT06859424

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement 1.

eFigure. Venn Diagram of the Overlap of Centers Participating in ACCESS, BMT CTN 1703, CIBMTR PRO Protocol

eTable. Detailed Insurance Status by Study and Conditioning Regimen

jamanetwopen-e2610839-s001.pdf (285.7KB, pdf)
Supplement 2.

ACCESS Trial Protocol and Statistical Analysis Plan: PRO Protocol

jamanetwopen-e2610839-s002.pdf (2.6MB, pdf)
Supplement 3.

Data Sharing Statement

jamanetwopen-e2610839-s003.pdf (12.7KB, pdf)

Articles from JAMA Network Open are provided here courtesy of American Medical Association

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