Real-world utilization and outcomes of lenalidomide in MDS with low blasts and isolated deletion 5q (MDS w 5q).

Abstract

11198 Background: Lenalidomide is the preferred first-line agent for lower risk MDS w 5q. It is associated with higher rates of transfusion independence and cytogenetic remission and has demonstrated survival benefit in selected clinical trial populations. Large nationwide studies are lacking in this subgroup. Methods: We identified adults aged > 18 years with MDS w 5q diagnosed between 2006 and 2021 using the National Cancer Database (NCDB), corresponding to Lenalidomide approval. Demographic, socioeconomic characteristics, insurance status, Charlson-Deyo comorbidity index (CCI), and treatment variables were extracted. The primary outcome was receipt of lenalidomide therapy. Secondary outcomes included overall survival (OS). Patients were categorized into pre-Affordable Care Act (ACA) and post ACA periods. Multivariable logistic regression and relative risk models were used. OS was estimated using Kaplan-Meier methods and differences between groups were compared with log-rank tests. Multivariable Cox proportional hazards model was used to assess factors associated with survival. P < 0.05 was considered significant. Results: We identified 3,328 individuals with MDS w 5q, median age of 77 years; 56.1% were women. The majority were non-Hispanic white 87%, followed by 6% non-Hispanic blacks and 4% Hispanic patients. Predominant insurance type was Medicare (78.3%). CCI score of 2 and higher was present in 15%. Overall, 21% of patients received Lenalidomide. Utilization increased significantly in the post-ACA, compared with pre-ACA (32% vs 12%, p < 0.001). On multivariable analysis, post -ACA period was independently associated with higher odds of Lenalidomide receipt (OR 3.01-4.34, P < 0.001), while Medicaid was associated with lower likelihood of treatment compared with Medicare (OR 0.26-0.96, p = 0.04). Other demographic and socioeconomic variables were not independently associated with treatment receipt. Median OS for the overall cohort was 15.7 months. In multivariable Cox analysis, worse OS was associated with age > 80 (HR 1.0; ref = 61-70), receipt of chemotherapy (HR 1.35) and increasing commodity burden [CDS: HR 1.27; CDS:2 HR 1.45, CDS 3: HR 1.95; all p < 0.001). Female sex was associated with improved survival(HR 0.76; p < 0.001). Lenalidomide receipt was not independently associated with OS after adjustment (HR 1.05; p = 0.27). Conclusions: This is the largest study evaluating receipt of lenalidomide in MDS with 5q deletion. Lenalidomide utilization increased substantially following ACA implementation, leading to improved access to disease modifying therapy. However, Medicaid insurance was associated with lower treatment receipts. Survival outcomes were primarily driven by age, commodity burden and treatment intensity rather than Lenalidomide receipt, highlighting persistent disparities and limitations of registry-based analysis.