Molecular testing and targeted therapy use in lung cancer across state Medicaid programs.

Abstract

11036 Background: Comprehensive molecular testing is the standard of care for patients with metastatic non-small cell lung cancer (NSCLC) and is essential to identify patients with tumors harboring EGFR , ALK alterations that can be treated with efficacious targeted therapies. Prior work has shown that use of targeted therapies for NSCLC is lower than expected among Medicaid beneficiaries and rates of use may vary across state Medicaid programs. We used Medicaid claims and encounter data to estimate the rates of molecular testing and targeted therapy use across state Medicaid programs. Methods: Using Transformed Medicaid Statistical Information System Analytic Files (TAF) data from 2017 and 2018, we identified beneficiaries with new diagnoses of metastatic NSCLC who were continuously enrolled in Medicaid during the period of analysis. Among these patients, we identified claims for molecular tests that could identify EGFR or ALK alterations and claims for FDA-approved targeted therapies during a 120-day window around the first claim for antineoplastic therapy. We tabulated rates of molecular testing and targeted therapy use by state. We ran logistic regressions for molecular testing and targeted therapy use with patient characteristics, and then we used the regression coefficients to estimate adjusted rates of molecular testing and targeted therapy use for each state. Results: We included 41 states with complete TAF data in the study years. In these states there were 5,432 beneficiaries who initiated antineoplastic therapy for new diagnoses of metastatic NSCLC. The number of incident cases within each state Medicaid program ranged from 11 in Utah to 824 in California. In logistic regression, the characteristics associated with lower rates of molecular testing were male sex, high Charlson comorbidity indices, and lower income. The characteristics associated with low rates of targeted therapy use were older age, male sex, and lower education levels. The adjusted rate of molecular testing among patients with incident metastatic NSCLC across all state Medicaid programs was 55.9% with rates ranging from 39.2% in Texas to 69.3% in Washington state. The mean adjusted rate of targeted therapy use across state Medicaid programs was 8.6% with rates ranging from 3.4% in Michigan to 24.8% in New York. Conclusions: After adjusting for patient characteristics, there was substantial state-by-state variation in the rate of molecular testing and targeted therapy use among Medicaid beneficiaries with NSCLC. More work is needed to understand whether specific Medicaid policies such as prior authorizations or restrictions on access to diagnostic testing may contribute to the observed disparities.