Exposure to New Therapies and Treatment Delay in Multiple Myeloma: Experience from a Safety Net Hospital

Introduction:

Treatments for myeloma have evolved over the past several years with resultant improvements in survival. Two new medications, bortezomib (B) and lenalidomide (L), have played a major role in this development. Each has received FDA approval in the past 10 years. Both medications are relatively expensive and, due to its teratogenic effects, lenalidomide requires a pt training and education program before pharmacies may fill the prescription. In addition, specialty pharmacies need to be identified and prior approval is required from the insurance carrier. This study addresses whether or not a relatively underinsured, indigent population was able to receive these medications and in a timely fashion.

Methods:

Electronic medical records of all pts diagnosed with myeloma from 1/2005-12/2014 at MetroHealth Medical Center (a large safety net institution in Cleveland, OH) were reviewed.

88 pts were identified. Med age was 59 (35 -87); 50% were African American (AA), 43% caucasian (C), 1% Hispanic and 6% unknown. Health insurance status: 26% private; 35% medicare; 17% medicaid; and 22% were uninsured.

Results:

77% AA received either B or L or both vs 82% C pts (NS).

Overall, 17/88 (19%) never received either L or B. This included: 5 due to pt preference or co-morbidities which precluded treatment,; 2 who died before they could receive any therapy; 3 lost to follow-up before treatment could be started; 6 who received thalidomide and then either transferred care elsewhere, died or did not require another treatment; and 1 who transferred to another facility for stem cell transplant evaluation before treatment was initiated. Therefore, all 71 pts who were candidates and w/treatment data available received B or L. Of the 17 who did not get B or L: 6 were uninsured, 5 private insurance, 4 medicare, and 2 medicaid.

Overall, 66 pts received B; 31 received L.

Ave time from prescription to pt start of medication: 19.1 days for L (med 14.5d, range 0-65d) vs 1.56d for B (med 0d, range 0-20d), p<0.00001. The pts treated with L were not overrepresented from any particular insurance status (29% were uninsured; 19% medicaid; 29% medicare; 23% private). This payor mix was similar for those who received B (21% uninsured; 13% medicaid, 36% medicare and 30% private).

Conclusions:

In this underinsured, indigent population, all appropriate pts with myeloma received at least one of the 2 novel drugs. There was a statistically significant delay in treatment for those pts who were prescribed lenalidomide as compared to bortezomib (19.1 days L vs 1.56 days for B). It is not clear that this is a clinically significant difference but suggests that bortezomib containing regimens may be a better option in cases where urgent therapy is needed, particularly in this population.