Variation in Use of Lung Cancer Targeted Therapies Across State Medicaid Programs, 2020-2021

Abstract

ImportanceTargeted therapies for EGFR (OMIM 131550)– and ALK (OMIM 105590)–altered metastatic non–small cell lung cancer (NSCLC) substantially improve outcomes for some patients. However, use of these therapies is lower among Medicaid patients, and access to oncology care varies across state Medicaid programs. Evidence is lacking on how use of targeted therapies for metastatic NSCLC varies across state Medicaid programs.ObjectivesTo characterize state-level variation in the use of targeted therapies among Medicaid patients with metastatic NSCLC and to describe factors associated with this variation.Design, Setting, and ParticipantsThis cross-sectional study used publicly available data from the Medicaid Drug Utilization Database from 2020 and 2021 and peer-reviewed data on NSCLC incidence, the prevalence of EGFR and ALK alterations, and expected treatment durations to estimate expected use of targeted therapies for EGFR- and ALK-altered NSCLC in 33 states.ExposuresState-specific Medicaid programs and state policies and characteristics.Main Outcomes and MeasuresThe primary outcome was the estimated proportion of person-time of Medicaid patients with EGFR- or ALK-altered NSCLC associated with receipt of targeted therapy in each state Medicaid program. Nested linear regression models examined associations between the observed variation and state policies and characteristics.ResultsThere were an estimated 3461 person-years in which EGFR- and ALK-targeted therapies were indicated in 2020 and 2021. During these years, only 2281 person-years of EGFR- and ALK-targeted therapies were dispensed to Medicaid patients, suggesting that an estimated 66% of Medicaid patients with EGFR- and ALK-altered metastatic disease received indicated targeted therapies across all states. Rates of targeted therapy use ranged from 18% in Arkansas to 113% in Massachusetts; 30 of 33 states (91%) had lower rates of targeted therapy use than expected. The observed variation across state Medicaid programs was associated with Medicaid policies, the density of oncologists, and state gross domestic product per capita.Conclusions and RelevanceThis study suggests that rates of targeted therapy use among Medicaid patients with EGFR- and ALK-altered NSCLC were lower than expected and varied across state Medicaid programs. State policies and characteristics were associated with the observed variation, indicating where interventions could improve access to treatment and outcomes for patients with NSCLC.

Social Determinants of Health and Cancer Care: An ASCO Policy Statement

“…14 This predictably results in unacceptable disparities in access to quality cancer care: for Medicaid beneficiaries, the most promising precision cancer therapies are far too often underutilized. 15 However, SDOH can also affect cancer incidence and outcomes in more pervasive and long-lasting ways. The life course perspective provides a framework for understanding the role that exposures to adverse SDOH at specific periods during an individual's life can play in poor health outcomes.…”

American Cancer Society’s report on the status of cancer disparities in the United States, 2023

“…It has been estimated that about 7.8–24.4 million people could lose Medicaid coverage during the 12‐month unwinding period 109 . Moreover, variations in coverage, prior authorization for services, and copays across states can contribute to disparities in the receipt of certain treatments, such as targeted therapies, among individuals with Medicaid coverage 110 …”

Ferrying Oncologists Across the Chasm of Interpreting Biomarker Testing Reports: Systematic Support Needed to Improve Care and Decrease Disparities

“…2 Despite these efforts, available data show that not only is biomarker testing underperformed in a setting such as advanced non-small-cell lung cancer 3,4 -where biomarker testing is a standard of care 1,2 -but also treatment patterns fail to follow appropriate evidencebased pathways approximately 30% of the time even when the results are made available, 4,5 and prescribing patterns show striking variability across geography. 6 Moreover, the trajectory of biomarker testing and treatment patterns fails to show clear improvement over time. 3 At least half of medical oncologists and other cancer care professionals report a lack of confidence in interpreting genomic data 7 and that suboptimal interpretation is correlated with the volume of cases managed by an individual physician.…”

“…Given the high frequency of discordance between biomarker test results and delivered therapy after tests have been conducted and results made available to the treating oncologist, [4][5][6] we must conclude that expert interpretation should be normalized and integrated into the routine conduct of biomarker testing, rather than being variably and selectively offered as an add-on at the behest of a busy treating physician. Depending on its availability, expert interpretation of biomarker testing results for translation into management recommendations can either magnify or eliminate a disparity in access to support on the basis of where a patient receives cancer care.…”