Non-receipt of targeted and immunotherapies in diverse patients with metastatic cancers.
Authors: Veenstra Christine M. , Abrahamse Paul , Kurian Allison W. , Hawley Sarah T. , Farias Albert , Hamilton Ann S. , Ward Kevin C. , Katz Steven Jay 
Published: September 2024

93

Background:
The rapid evolution of molecularly targeted kinase inhibitors (TKIs) and immune checkpoint inhibitors (ICIs) in the treatment of metastatic cancer, coupled with high drug costs, raises potential for unwarranted variation in patient management. We evaluated correlates of non-receipt of TKIs and ICIs in a diverse, population-based sample of patients with metastatic non-small cell lung cancer (NSCLC), kidney and bladder (GU) cancer, and melanoma.
Methods:
We identified 2240 patients diagnosed in 2019 with metastatic NSCLC, GU cancer, or melanoma and reported to the Georgia or Los Angeles SEER registries. Using SEER registry data, we linked all patients to a managing oncology physician. We collected data from the managing physician regarding receipt of TKIs and ICIs. We used bivariate analyses and multivariable logistic regression models to assess associations between non-receipt of TKIs and ICIs and patient-level factors.
Results:
We present results for a preliminary sample (N=894). About half (55%) of the patients had NSCLC, 31% had GU cancer, and 14% had melanoma. The mean age was 62 (SD 12); 59% were male; 65% were White, 16% were Black, 11% were Hispanic, and 7% were Asian; 52% had Medicare, 29% had private insurance, 9% had Medicaid, and 4% had no insurance; 89% resided in urban areas, 11% resided in rural areas. 22% lived in a census tract area with >20% of the population living below the poverty level. The Table shows that in bivariate analyses, non-receipt of TKIs was associated with NSCLC, older age, male sex, non-white race, and non-private or no insurance (all p<0.05). After adjustment, non-receipt of TKIs was associated with NSCLC, older age, male sex, and race. Asian and Hispanic patients had lower rates of non-receipt, and Black patients had higher rates. In bivariate analyses, non-receipt of ICIs was associated with NSCLC and GU cancer (p=0.004); this association remained significant after adjustment.
Conclusions:
Non-receipt of TKIs was associated with important non-clinical factors including race and sex. Non-receipt of ICIs was associated only with cancer type. These findings suggest that policy-relevant factors such as out-of-pocket costs for oral cancer therapies and differential access to molecular sequencing may contribute to unwarranted variation in receipt of TKIs.

Bivariate analyses of non-receipt.

Did not Receive TKI
Did not Receive ICI

%

P

%

P

Cancer type NSCLC GU Melanoma
786572
0.002
313015
0.004

Age <50 50-64 65-74 75-84 85+
5471757986
<0.001
2625302940
0.385

Sex Male Female
7670
0.048
2631
0.085

Race & Ethnicity White Black Hispanic Asian Other
7579655860
0.002
2329312927
0.981

Marital Status Married Unmarried
7373
0.645
2630
0.158

Insurance Medicare Medicaid Private Other government None
7075637080
<0.001
3130215031
0.101

Geography Urban Rural
7375
0.784
2826
0.567

% population below poverty level 0-5% 5-<10% 10-<20% 20-100%
69717774
0.314
29273222
0.138