Barriers to Care Delay Costly Multiple Myeloma Treatment

Photo Credit: Nemes Laszlo

“Disparities in time to prescription fill for anti-myeloma drugs exist based on socio-demographic factors. Future research should examine the role of precertification criteria and out-of-pocket costs in delays with recommended care,” Hamlet Gasoyan, PhD, and colleagues wrote in the abstract of their poster presentation at the 2024 ASCO Annual Meeting.

In people with newly diagnosed multiple myeloma, high out-of-pocket costs or the burdensome insurance precertification process can delay the start of costly anti-myeloma agents and can lead some patients to resort to less-costly corticosteroids.

“Disparities in treatment initiation for multiple myeloma vary by demographic characteristics and insurance type. However, with costly oral anti-myeloma medications, less is known about disparities in time to treatment initiation, which prompted us to conduct this retrospective cohort study,” Dr. Gasoyan says.

The researchers used Taussig Cancer Center’s Myeloma Patient Registry to identify adults newly diagnosed with multiple myeloma from 2017 through 2021. The researchers searched electronic health records data for:

• Time from initial diagnosis to receipt of FDA-approved anti-myeloma drug, including versus excluding corticosteroids.
• Time to initial prescription fill for FDA-approved anti-myeloma agent excluding corticosteroids.
• Association of race, sex, primary insurance type, area deprivation index (ADI), urbanicity, and time to initial prescription fill for anti-myeloma drug excluding corticosteroids. The latter was assessed as cumulative incidence at 30 days since initial diagnosis using the log rank test and multivariable Cox regression.

The 723 patients they identified averaged 67 years of age at diagnosis, and 55% were male, 77% White, 22% Black, and 1% other races; 36% were covered by private insurance, 28% by traditional Medicare, 25% by Medicare Advantage, 8.4% by Medicaid, and 1.8% were considered self-pay/other. The median follow-up period was 784 days (interquartile range, IQR, 415-1313). While 83% of patients resided in a metropolitan area, 37% lived in an area in the most disadvantaged quartile of the ADI.

The median time to receive anti-myeloma treatment was 10 days (IQR, 2-24), including corticosteroids, versus 18 days (IQR, 8-37), excluding corticosteroids. The median time to initial prescription fill for an anti-myeloma medication, excluding corticosteroids, was 31 days (IQR, 16-75).

The authors found the following cumulative incidences of prescription fill for anti-myeloma drugs excluding corticosteroids at 30 days:

• 40% (95% CI, 36%-44%) in White patients, 28% (95% CI, 21%-36%) in Black patients, and 17% (95% CI, 0.42%-64%) in other races (P=0.009) and adjusted HR for Black patients versus White (0.63; 95% CI, 0.44-0.90).
• 31% (95% CI, 25%-38%) in patients with traditional Medicare, 37% (95% CI, 30%-44%) in those with Medicare Advantage, 44% (95% CI, 38%-50%) with private insurance, 34% (95% CI-23%, 48%) with Medicaid, and 31% (95% CI, 9.1%-61%) were self-paying or had other insurance (P=0.07) and adjusted HR for private insurance versus traditional Medicare (1.4; 95% CI, 1.04-1.93).
• 40% (95% CI, 36%-44%) treated in Taussig Cancer Center and 25% (95% CI, 17%-34%) in regional hospitals (P=0.003) and adjusted HR for regional hospitals (0.59; 95% CI, 0.40-0.89).

Oral Anti-Myeloma Drugs Are Unaffordable for Many Patients

“The introduction of oral anti-myeloma medications, such as immunomodulatory drugs lenalidomide and pomalidomide, is believed to have had a major role in the improved survival of patients with multiple myeloma over the past two decades,” Dr. Gasoyan says.

But while oral formulations are more convenient, their high cost can keep them out of reach of many patients.

“Patient support programs that help pay for prescriptions are challenging to navigate. For example, the multistep process of obtaining lenalidomide can lead to delays in treatment initiation,” Dr. Gasoyan explains. “That process involves the risk evaluation and mitigation strategy (REMS) program requirements for which patients and professionals complete mandatory surveys, as well as the time-consuming insurance prior authorization process. In addition, only specialty pharmacies dispense the medications, and courier delivery can be delayed.

“Our quantitative measurements of the delays involved in initiating costly oral multiple myeloma medications highlight the need to focus on the barriers to timely treatment initiation, he notes. “Understanding how race and social determinants of health affect delays in care is critical if we are to plan health policy initiatives and patient navigation programs aimed at achieving health equity.”