Many Patients Don’t Receive Indicated Targeted NSCLC Therapy

About one third of Medicaid patients with metastatic non–small cell lung cancer (NSCLC) are not receiving indicated targeted therapy, a new analysis suggests.

Researchers found that the rates of targeted therapy use among those with EGFR– and ALK alterations varied widely across US states in 2020 and 2021, with only 18% of eligible Medicaid patients in Arkansas receiving appropriate targeted therapies.

The findings suggest that only “an estimated 66% of Medicaid patients with EGFR– and ALK-altered metastatic disease received indicated targeted therapies across all states,” the study authors, led by Thomas J. Roberts, MD, MBA, Department of Medicine, Massachusetts General Hospital, Boston, write. Roberts and colleagues extrapolated that this underuse could mean “an estimated 855 preventable years of life lost” over the 2-year study period.

The research was published online in JAMA Network Open on January 25.

Despite being required by federal law to cover drugs for almost all indications approved by the US Food and Drug Administration (FDA), financial concerns have prompted some Medicaid programs to reduce the services provided, including the use of costly drugs. Research indicates that rates of guideline-concordant care are in fact lower among Medicaid patients and that the access that these patients have to evidence-based oncology care varies across the US.

To better understand the patterns of targeted therapy use in state Medicaid programs, Roberts and colleagues obtained prescription data from the Medicaid Drug Utilization Database nationally and for states with at least 20 estimated person-years of first-line targeted therapy use for metastatic NSCLC.

The authors also gathered information from a variety of registries and peer-reviewed publications to determine the incidence of NSCLC and estimate the person-years of expected EGFR and ALK-targeted therapy use in each state’s Medicaid population. They used multivariable linear regression models to evaluate state-level characteristics.

As of 2020, the FDA had approved eight targeted therapies to treat NSCLC tumors harboring alterations in EGFR and ALK genes, but the researchers focused on the EGFR-targeted drug osimertinib (Tagrisso) and ALK-targeted alectinib (Alecensa), which have been considered the standard of care since 2018.

Roberts and colleagues found that across all state Medicaid programs, 2281 person-years of EGFR– and ALK-targeted therapy were dispensed in 2020 and 2021, with osimertinib and alectinib accounting for 83% of prescriptions. The authors estimate that the expected use of those agents in that time is 3461 person-years, assuming standard treatment durations for osimertinib and alectinib.

The authors acknowledge that, without access to individual claims and medical records, they could not determine the exact number of patients with EGFR– and ALK-altered metastatic NSCLC.

But they did determine that “just 66% of person-years in whom targeted therapies were indicated in 2020 and 2021 were associated with use of those medications, suggesting that at least 500 Medicaid patients with a diagnosis of EGFR– or ALK-altered metastatic NSCLC during these years did not receive targeted therapy when indicated.” They further extrapolated that “this underuse could have led to an estimated 855 preventable years of life lost during the period of analysis.”

On the state level, the authors estimate that there were 1991 person-years of osimertinib and alectinib use, vs 3258 person-years of expected use, across 33 individual states. In only three states were dispensing volumes in line with expected levels, while in 12 states, dispensing volumes were “somewhat below” expected levels, and in 18 states, the volumes were “substantially below expected levels,” the team notes. Use ranged widely from a low of 18% in Arkansas and 19% in Georgia to a high of 113% in Massachusetts.

In addition, Medicaid state access scores, the density of oncologists in each state, and the state gross domestic product (GDP) were related to the use of targeted therapies. The team found that each additional point score was associated with a 10.2% increase in osimertinib and alectinib use. Use rose to 13.2% when the per-capita number of oncologists was considered.

Increasing state GDP was also associated with an increase in targeted therapy use of 0.9%. The final model accounted for 40% of the variation in targeted therapy use across states.

“Where underuse is confirmed, policy makers should examine prescribing programs and practices in states to ensure that patients who require these life-prolonging medications are able to access them,” Robert and colleagues concluded.

Roberts has relationships with Biocon Biologics Ltd and Conquer Cancer Foundation outside the submitted work. No other relevant relationships have been disclosed.

JAMA Netw Open. Published online January 25, 2023. Full text

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