CLINICAL NEWS
Literature Scan
• PDP coverage without Medicaid
(n=3,823; 34%)
• OCC (n=3,607; 37%)
• Medicare/Medicaid dual enrollment
(n=1,405; 14%)
Beneficiaries actively changed their
prescription coverage status after my-
eloma diagnosis; for example, 41 percent
of those without coverage at diagnosis
obtained either PDP or OCC by the fol-
lowing January. However, PDP enrollees
at diagnosis universally maintained their
coverage.
Baseline characteristics were similar
between patients who did or did not
switch coverage, except that people who
obtained PDP or OCC were more likely to
have no recorded comorbidities (64% vs.
54%; p=0.001) and to undergo a hemato-
poietic cell transplantation (11% vs. 7%;
p=0.015).
The overall proportion of beneficia-
ries who received active antimyeloma
care increased slightly during the study
period, from 88 percent in 2006 to 91
percent in 2011. The proportion who
received any parenteral chemotherapy
also increased, doubling from 24 to 48
percent, “mainly as a result of the ex-
panding use of bortezomib,” the authors
noted.
“Our results
highlight the
increasing
need to provide
financial
guidance and
discuss economic
repercussions of
cancer therapy.”
—ADAM J. OLSZEWSKI, MD
In the group of PDP enrollees, bortezo-
mib use increased from 13 to 44 percent
during the study period, but the proportion
of patients who received IMiDs remained
“fairly steady” at 31 percent.
The researchers observed that treat-
ment of myeloma differed substantially by
patients’ type of prescription drug cover-
age ( TABLE 3 ).
Compared with beneficiaries without
74
ASH Clinical News
TABLE 3.
Receipt of Therapy Per Drug Coverage
Adjusted Relative Risk (95% CI)
Prescription Drug Coverage
Active Care for Myeloma Any Parenteral
Chemotherapy Classic Cytotoxic Agent Bortezomib-Based
Regimen
None Reference Reference Reference Reference
PDP 1.06 (1.05-1.07) 0.86 (0.80-0.93) 0.62 (0.51-0.76) 0.91 (0.82-1.02)
OCC 1.03 (1.01-1.04) 0.95 (0.86-1.05) 0.94 (0.83-1.07) 0.98 (0.87-1.09)
Medicaid/Medicare dual enrollee 1.02 (1.00-1.04) 0.78 (0.69-0.89) 0.68 (0.56-0.83) 0.79 (0.65-0.95)
PDP = Part D plan; OCC = other creditable coverage
TABLE 4.
Survival Outcomes Per Drug Coverage
Prescription Drug Coverage
Median OS (95% CI), years
3-Year OS (95% CI), %
None 1.7 (1.5-2.0) 39.2 (36.7- 41.7)
PDP 2.6 (2.5-2.7) 45.9 (44.2-47.6)
OCC 2.6 years (2.5-2.7 years) 45.5 (43.8-47.1)
Medicaid/Medicare dual enrollee 1.6 years (1.5-1.8 years) 34.5% (32.0-37.1)
PDP = Part D plan; OCC = other creditable coverage; OS = overall survival
coverage, PDP enrollees were:
• 6% more likely to receive active care
for myeloma
• 14% less likely to receive parenteral
chemotherapy
• 38% less likely to receive classic cyto-
toxic agents
(P values were not reported for these
comparisons.)
However, there were no significant dif-
ferences in bortezomib use – likely because
bortezomib was already covered under the
drug benefits of traditional Medicare plans.
OCC recipients were 3 percent more
likely to receive active antimyeloma ther-
apy, compared with beneficiaries without
coverage, but again, the use of parenteral
regimens did not differ significantly (p
values not reported).
After a median follow-up of 4.9 years
(range not reported), 70 percent of pa-
tients in the study died. Median survival
was 2.3 years (range = 2.2-2.4 years) and
the three-year rate of overall survival (OS)
was 43.1 percent ( TABLE 4 ).
While there were no differences in
survival between the OCC and PDP
groups, patients with OCC and PDP
coverage had significantly longer survival,
compared with those without coverage:
• PDP: adjusted restricted mean sur-
vival time (RMST) ratio = 1.16 (95%
CI 1.11-1.20; p value not reported)
• OCC: adjusted RMST ratio = 1.16
(95% CI 1.12-1.21; p value not
reported)
The researchers reported that Medicaid
dual enrollees had notably worse OS,
which is consistent with their burden
of comorbidities and poor performance
status, but, after adjustment for these
unfavorable baseline characteristics,
Medicaid dual enrollees actually had
better OS than those without coverage
(adjusted RMST ratio = 1.08; 95% CI
1.03-1.13; p value not reported).
Although patients with Medicare
PDP or OCC coverage appeared to have
better survival outcomes, “we could not
discern whether worse survival in the
group without coverage was a result of
not receiving therapy at all, an inability
to access immunomodulatory drugs, or
poor control of other medical issues,” the
authors concluded. “As most patients with
myeloma in the United States are covered
by Medicare, our results have important
implications both for the clinicians who
care for these patients and for health-care
policy that tackles coverage of oral and
parenteral anticancer therapy.”
The authors noted that this analysis was
limited by its reliance on retrospective data.
This introduced the potential for “unob-
served clinical differences between benefi-
ciaries with and without prescription drug
coverage,” which may have contributed to
differences in mortality outcomes.
Also, the comparison of treatments
was restricted to parenteral regimens,
because oral IMiDs covered by PDP plans
were tracked, but nonbeneficiaries who
obtained oral agents through non-PDP
insurance plans would not have been
recorded in the Medicare database. “The
inability to [comprehensively] iden-
tify oral chemotherapy [use] is a major
hurdle for health services research using
Medicare data – a problem of increasing
importance … [considering that] IMiDs
are covered by more than 93 percent of
Medicare prescription plans,” they added.
The study exclusion criteria also means
that these findings cannot be extrapolated
to Medicare managed-care plan enrollees
or to younger patients.
“Our finding of an association be-
tween prescription coverage at diagnosis
and survival in myeloma will need to be
evaluated in other settings where oral
anticancer therapies can provide substan-
tial clinical advantage,” Dr. Olszewski said.
“As health-services researchers, we are
looking forward to ongoing initiatives that
could enrich the data in ways that will
make the analyses more impactful for the
clinical practice.”
The study authors reported financial
relationships with Spectrum Pharmaceuti-
cals, Genentech, TG Therapeutics, Celgene,
Kyowa Kirin, Jazz Pharmaceuticals, Tolero
Pharmaceuticals, Boehringer Ingelheim,
and the PhRMA Foundation. ●
REFERENCE
Olszewski AJ, Dusetzina SB, Trivedi AN, Davidoff AJ. Prescription
drug coverage and outcomes of myeloma therapy among Medicare
beneficiaries. J Clin Oncol. 2018;36:2879-86.
December 2018