Treatment and outcomes for multiple myeloma (MM) have been greatly improved by the introduction of parenteral chemotherapy and novel oral agents such as lenalidomide and thalidomide. However, the cost of those agents typically exceeds $5,000 per month, which continues hinder their accessibility, according to Adam J. Olszewski, MD, in the Division of Hematology-Oncology at Alpert Medical School at Brown University, in Providence, RI.  He discussed the ongoing financial difficulties for patients, insurers, and healthcare systems on Monday, December 5, at the 58th American Society of Hematology Annual Meeting and Exposition in San Diego, CA. 

The study authors specifically discussed Medicare beneficiaries in the United States, who continue to have disparate coverage for oral chemotherapy.

“Coverage for oral agents has been available since 2006 for those purchasing Part D prescription plans (PDP),” Olszewski said. “But such plans impose substantial out-of-pocket expenses through the donut-hole coverage gap and coinsurance required even in the catastrophic phase.” However, cost sharing can be nearly eliminated for qualifying low-income patients who receive Part D Low-Income Subsidy (LIS). 

Researchers sought to assess the relationship between Medicare Part D and LIS policies with the use and out-of-pocket costs of novel antimyeloma agents. To do so, they used data from more than 19,000 patients in the Surveillance, Epidemiology, and End Results database linked to Medicare claims from 2000–2012. Patients were at least 65 years old, diagnosed with myeloma between 2001 and 2011, and had fee-for-service Medicare insurance. Patients had a mean age of 77 and most were men (54%). 

The researchers then classified patients in the post-Part-D era (2006–2012) according to their prescription coverage at diagnosis as those having PDP without LIS, PDP with LIS, or no coverage. After identifying which patients had received first-line parenteral chemotherapy and oral agents, they compared parenteral and oral chemotherapy use between pre-Part-D (2001–2005) and post-Part-D (2006–2012) eras and use of lenalidomide and thalidomide among patients who had PDP with or without LIS. 

Overall, Olszewski and colleagues found that treatment proportions increased in the post-Part-D era. 

For example, 52% of the over 19,000 patients had a record of any chemotherapy within one year from myeloma diagnosis. This percentage increased from 42% in pre-Part-D era to 61% after Part D introduction. What’s more, during the post-Part-D era, the proportion of patients who were treated with parenteral chemotherapy increased for those without prescription coverage, but it decreased in favor of oral regimens for those who acquired a PDP with or without LIS. Of patients with no PDP coverage, 41% purchased it within one year of their myeloma diagnosis.

The trends were similar with the upfront use of novel oral agents for patients with PDP. 

For example, lenalidomide mainly replaced thalidomide between 2007 and 2011, but up to 40% of patients did not receive novel agents as part of their regimen. And recipients of LIS had a 17% higher probability of being treated with a novel oral agent. 

Substantial differences were also seen in cost-sharing. The median patient cost-sharing for the first prescription was $3 for patients with LIS and $3,120 without LIS. 

“The proportion of Medicare beneficiaries actively treated with chemotherapy for myeloma increased after the introduction of Medicare Part D in 2006,” said Olszewski. The increased prescription coverage correlated to the use of novel agents for those receiving Part D LIS. “Our findings suggest concerning disparities in equitable access to novel but expensive oral antimyeloma agents based on insurance coverage for oral chemotherapy. Further research should determine if policies for oral chemotherapy coverage translate into disparities in survival or other outcomes.”