Disparities in First-line Treatment Initiation Among US Medicare Beneficiaries with Myelodysplastic Syndromes (MDS)

Christopher R. Cogle, MD1, Sheila R. Reddy, PhD, RPh2, Eunice Chang, PhD2, Sohum Gokhale, MPH2, Michael S. Broder, MD, MSHS2, Michael McGuire, DPharm3

1University of Florida, Gainesville, FL, United States; 2Partnership for Health Analytic Research (PHAR), LLC, Beverly Hills, CA, United States; 3Celgene Corporation, Summit, NJ, United States

CATEGORY: Myelodysplastic Syndromes

KEYWORDS: myelodysplastic syndromes, lenalidomide, azacitidine, decitabine, health outcomes research

OBJECTIVE: To measure contemporary use of first-line therapy for MDS, which can reduce the need for blood transfusions, and to determine patient/disease characteristics associated with first-line treatment initiation.

DESIGN: Retrospective, claims-based analysis of SEER-Medicare database.

PATIENTS: Newly-diagnosed MDS (ICD-O-3: 9980–9989) patients were identified by having ≥1 claim for first-line treatment, i.e., hypomethylating agent (HMA; azacitidine or decitabine) or lenalidomide (LEN), during an identification period (1/1/2009–12/31/2013). The first HMA/LEN claim marked the index date. HMA/LEN initiators were matched 1:1 with non-initiators by diagnosis year and quarter and SEER-Medicare MDS Risk Score, and assigned the same index date. All patients resided in SEER regions, had MDS as first cancer diagnosis, and were diagnosed ≤12 months before index date (baseline). Patients with AML, those not continuously enrolled at baseline, or with claims for HMA/LEN during baseline were excluded. 

MEASURES: Patient and area-level baseline measures were examined as predictors of HMA/LEN initiation: age, sex, race, region, rural location, Charlson Comorbidity Index (CCI), del(5q) syndrome, prior transfusions (y/n), prior hematopoietic-stimulating agent use (≥12 weeks/<12 weeks/none); and census-tract residential variables of median annual income, college-educated residents, and residents below the poverty line (>40%/20–40%/<20%). 

RESULTS: 2,139 of 7,700 (27.8%) newly-diagnosed MDS patients used HMA or LEN; 630 were initiators meeting all selection criteria. HMA (n=498) and LEN (n=132) initiators versus matched non-initiators were younger at diagnosis (76.2 vs 82.0 years; p<0.001) and predominantly White (86.2% vs 83.0%; p=0.034). Differences in sex, rural location, and CCI were not significant. In the logistic regression model, positive predictors of receiving first-line treatment were del(5q) syndrome (OR[95% CI] 4.62[2.31–9.26]), prior transfusion (2.98[2.23–3.98]), and prior hematopoietic-stimulating agent (EPO/G-CSF) use ≥12 weeks (2.01[1.22–3.31]). 

Advanced age (80–84 years 0.35[0.17–0.74]; ≥85 years 0.12[0.06–0.26] vs ≤64), census-tract residents below the poverty line >40% (0.23[0.07–0.74] vs <20%), and CCI (0.93[0.89-0.97]) decreased likelihood of treatment initiation.

CONCLUSIONS: Advanced age and poverty may contribute to disparities in first-line treatment initiation among MDS patients. Other treatment decisions are likely guided by clinical factors (e.g. disease severity, comorbidities, prior treatments).

Research funded by Celgene. 

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