Medicaid Enrollees Appear To Be Missing Out on Targeted Treatment for NSCLC, Harvard Researchers Find

1 out 3 Medicaid patients who might have benefited from targeted therapy —mainly Tagrisso and Alecensa — for metastatic lung cancer did not receive it, according to estimates by a trio Harvard-affiliated researchers.

Approximately 500 people covered by Medicaid did not receive targeted treatment for nonsmall cell lung cancer (NSCLC) that would have likely extended their lives, according to research findings reported today in JAMA Network Open. The researchers estimated that underuse of targeted therapy — mainly Tagrisso (osimertinib) for NSCLC with targetable EGFR mutations and Alecensa (alectinib) with targetable ALK mutations— resulted in 855 preventable years of life loss during the 2020-2021 study period.

Rates of the use of Tagrisso and Alecensa varied among the 33 states included in the research conducted by Thomas J. Roberts, M.D., MBA, Aaron S. Kesselheim, M.D.,J.D., M.P.H., and Jerry Avorn, M.D., of Program on Regulation, Therapeutics and Law at Harvard-affiliated Brigham and Women’s Hospital in Boston.

According to their calculations, only Massachusetts, Hawaii and New York had Medicaid populations for which the targeted NSCLC therapies were dispensed in the expected range Minnesota, Tennessee, Alabama, Georgia and Arkansas ranked the lowest.

Overall, their calculations show that roughly 1 in 3 patients covered by Medicaid with metastatic lung cancer with EGFR and ALK mutations that would have been appropriately treated with targeted therapy did not receive it.

“We found evidence of underuse of targeted therapies for NSCLC among Medicaid beneficiaries and substantial variation in the use of these efficacious medication across the states,” they concluded. “Where underuse is confirmed, policymakers should examine prescribing programs and practices in states to ensure that patients who require these life-prolonging medications are able to access them.”

Roberts and his colleagues used the Medicaid Drug Utilization Database and IQVIA’s Longitudinal Access and Adjudication Data Set to calculate the number of prescriptions. They calculated the number of people who were candidates for treatment with the EGFR- and ALK-targeted indirectly using demographic data about Medicaid populations and prevalence data for the EGFR- and ALK-mutated NSCLC in those populations; for ALK mutations, they assumed a prevalence of 3% of metastatic NSCLC cases for all races and ethnicities.

In the limitations section of the paper, they noted that they could not determine the exact number of patients with EGFR- and ALK-altered metastatic NSCLC. They also mentioned limitation that Tagrisso and Alecensa usage data was calculated on an aggregate basis.

When Roberts, Kesselheim and Avorn looked for explanations for the state-to-state variation, they found that number of oncologist per 100,000 Medicaid enrollees and Medicaid policies that affected access, such as prior authorization requirements and coverage of testing, were factors. But a state’s GDP per capita was the most influential factor in explaining the variation.

“State GDP, the dominant variable in the multivariable model, may be associated with access to these medications through changes in state budgets and policies or through community characteristics that are correlated with wealth, such as education, community resources, and smoking rate,” they wrote.