What Are Health Disparities?

The National Cancer Society defines cancer health disparities as “adverse differences in cancer measures such as the number of new cases, number of deaths, cancer-related health complications, survivorship, and quality of life after cancer treatment, screening rates, and stage of diagnosis that may exist among groups”. These disparities can be based on geographical differences, racial differences, and socio-economic disparities.¹

Accessibility to Care Considerations for Rural and Underserved Patients

As the complexity of care delivery increases, the probability of missing or delaying effective treatments becomes more dependent on organizational factors such as geographic location. Factors such as the organizational structure of the treatment location, for example if it is a local community cancer or large academic cancer center, is a factor that has been shown to influence access to care including immunotherapy.²

Geographic barriers contribute to disparities in the use of cancer treatments such as immunotherapy. One challenge is the fact that there are 14 states without any National Institutes of Health (NIH) affiliated cancer centers, which affects access to cancer treatment for millions of people.³

The availability of clinical trials and the latest therapies tend to be concentrated in urban settings with large academic centers, which limits access in rural and suburban centers. Results from a 2023 study showed that adoption of immunotherapy within 2 years of FDA approval was 11% lower in rural practices compared with urban practices. This was observed even though barriers to administering most cancer immunotherapies are considered to be low given that specialized training and equipment is not required for their administration. Frequent visits to an urban academic center for treatment may not be feasible for patients given the time and financial requirements. Location barriers and financial barriers also affect healthcare providers because rural community oncology centers usually do not have the same funding as larger, urban, academic centers.^4,5

Specific to immunotherapy, patients in rural and remote regions have the challenge of long travel distances and frequent transportation-related costs that are associated with administration of intravenous infusions.^6,7 This provides the support that subcutaneous immunotherapy can have an important role in this patient population.

Subcutaneous Immunotherapies and Benefits for Rural and Underserved Patients

Approved Subcutaneous Immunotherapies

The anti PD-L1 checkpoint inhibitor atezolizumab and hyaluronidase-tqjs (Tecentriq Hybreza) was approved in September 2024 as monotherapy, in combination with chemotherapy, and in combination with targeted therapies. In December 2024, the FDA approved a subcutaneous formulation of the anti-PD-1 checkpoint inhibitor nivolumab (Opdivo Qvantig) as monotherapy, monotherapy maintenance following completion of nivolumab (Opdivo) plus ipilimumab (Yervoy) combination therapy, or in combination with chemotherapy or cabozantinib. In September 2025, the anti-PD-1 checkpoint inhibitor pembrolizumab and berahyaluronidase alfa-pmph (Keytruda Qlex) injection was approved.⁸

Benefits of Subcutaneous Immunotherapies

Importantly, availability and incorporation of subcutaneous formulations of immunotherapies in treatment plans has the potential to make therapy more accessible. This is especially relevant for patients who live in rural and underserved communities.

Subcutaneous formulations of immunotherapies save patients and providers 30 or more minutes in treatment time because they take less time to administer. They can also make treatment more accessible for some patients by reducing the frequency of hospital visits and the need to travel long distances to infusion centers. Subcutaneous checkpoint inhibitors can be administered by a healthcare provider in multiple settings such as an infusion center, a doctor’s office, or community, which provides flexibility particularly for patients who live far from treatment centers and those who require long-term maintenance therapy. When these barriers are removed, treatment adherence and outcomes may be improved.^8-10

Results from a publication based on a survey conducted in 201 patients who were experienced with subcutaneous and intravenous cancer treatments showed that 89.6% of patients preferred subcutaneous therapy and 5.5% of patients preferred IV therapy. In addition, patients were typically more satisfied with subcutaneous treatment (78.6% versus 33.3% for intravenous therapy). Appointment travel time, total time spent at a treatment facility, reduced treatment burden, improved independence and convenience, as well as the ability to cope with their illness were factors affecting satisfaction with treatment.¹¹

Final Thoughts on Subcutaneous Therapies in Patients in Rural and Underserved Communities

The use of subcutaneous immunotherapy and the benefits to patients in rural and underserved communities support overall healthcare trends to improve healthcare efficiency. Having selected patients receive treatment closer to home in community hospitals, ambulatory care centers, and/or outpatient facilities can be beneficial; however, subcutaneous therapies may not be appropriate for all patients. For example, patients who have active toxicity, clinical deterioration, and/or poor performance status may not be ideal candidates. Subcutaneous therapies may also not be appropriate for patients who started their immunotherapy as IV therapy, who receive other IV treatments, or for those who have other reasons to travel to the cancer center, such as for lab work or healthcare provider appointments.^8,12

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References

1. Cancer Health Disparities. American Association for Cancer Research. https://www.aacr.org/patients-caregivers/about-cancer/cancer-health-disparities. Accessed on September 22, 2026
2. Osarogiagbon RU, Sineshaw HM, Unger JM, et al. : Immune-based cancer treatment: Addressing disparities in access and outcomes. Am Soc Clin Oncol Educ Book:66-78, 2021.
3. Mallet, M. Advancing Cancer Care in Rural and Underserved Communities. December 16, 2024. Available at: https://www.cancerresearch.org/blog/advancing-cancer-care-in-rural-and-underserved-communities
4. Carroll CE, Landrum MB, Wright AA, Keating NL. Adoption of Innovative Therapies Across Oncology Practices—Evidence From Immunotherapy. JAMA Oncol. 2023;9(3):324–333.
5. Karlovitch S. Breaking the Lock: Immunotherapy Transformed Oncology, But Barriers Still Limit Who Benefits. April 22, 2026 Available at: https://www.bloodcancerstoday.com/post/breaking-the-lock-immunotherapy-transformed-oncology-but-barriers-still-limit-who-benefits
6. Disparities in Clinical Research and Cancer Treatment. AACR Cancer Disparities Progress Report. Available at: https://cancerprogressreport.aacr.org/disparities/cdpr26-contents/cdpr26-disparities-in-clinical-research-and-cancer-treatment/
7. Ashrafzadeh S, Asgari MM, Geller AC. The Need for Critical Examination of Disparities in Immunotherapy and Targeted Therapy Use Among Patients With Cancer. JAMA Oncol. 2021;7(8):1115-1116.
8. The Importance of Subcutaneous Checkpoint Inhibitors for Cancer. AIM with Immunotherapy. Available at: https://aimwithimmunotherapy.org/optimizing-immunotherapy/subcutaneous-checkpoint-inhibitor-therapy-for-cancerwhat-healthcare-providers-need-to-know/
9. Gupta A, Tregear M, Pace MB et al. Stick With Intravenous or Give Subcutaneous a Shot? Time and Other Considerations When Evaluating Cancer Drug Formulations. JCO Oncol Pract. 2024;219:267-269.
10. From Infusion to Injection: The Promise of Subcutaneous Nivolumab. GU Oncology Now. February 25, 2025. Available at https://www.guoncologynow.com/post/from-infusion-to-injection-the-promise-of-subcutaneous-nivolumab
11. Epstein, R., Krenitsky, J. & Sarocco, P. Real-World Quantitative Insights into the Treatment Experience of Patients with Cancer in the USA with Subcutaneous Versus Intravenous Drug Delivery. Oncol Ther. 2025;13:695–710.
12. Muñoz-Couselo E, Lostes J, Pretelli G, Peiró M, Barrubés J, Bayona X. Subcutaneous immunotherapy as a catalyst for decentralized, oncologist-led cancer care: a mixed-methods analysis. Clin Transl Oncol. 2026 Jun 8. doi: 10.1007/s12094-026-04393-7. Epub ahead of print. PMID: 42258141.