Association of Historical Housing Discrimination and Colon Cancer Treatment and Outcomes in the United States

PURPOSE

In the 1930s, the federally sponsored Home Owners' Loan Corporation (HOLC) used racial composition in its assessment of areas worthy of receiving loans. Neighborhoods with large proportions of Black residents were mapped in red (ie, redlining) and flagged as hazardous for mortgage financing. Redlining created a platform for systemic disinvestment in these neighborhoods, leading to barriers in access to resources that persist today. We investigated the association between residing in areas with different HOLC ratings and receipt of quality cancer care and outcomes among individuals diagnosed with colon cancer-a leading cause of cancer deaths amenable to early detection and treatment.

METHODS

Individuals who resided in zip code tabulation areas in 196 cities with HOLC rating and were diagnosed with colon cancer from 2007 to 2017 were identified from the National Cancer Database and assigned a HOLC grade (A, best; B, still desirable; C, definitely declining; and D, hazardous and mapped in red). Multivariable logistic regression models investigated association of area-level HOLC grade and late stage at diagnosis and receipt of guideline-concordant care. The product-limit method evaluated differences in time to adjuvant chemotherapy. Multivariable Cox proportional hazard models investigated differences in overall survival (OS).

RESULTS

There were 149,917 patients newly diagnosed with colon cancer with a median age of 68 years. Compared with people living in HOLC A areas, people living in HOLC D areas were more likely to be diagnosed with late-stage disease (adjusted odds ratio, 1.06 [95% CI, 1.00 to 1.12]). In addition, people living in HOLC B, C, and D areas had 8%, 16%, and 24% higher odds of not receiving guideline-concordant care, including lower receipt of surgery, evaluation of ≥12 lymph nodes, and chemotherapy. People residing in HOLC B, C, or D areas also experienced delays in initiation of adjuvant chemotherapy after surgery. People residing in HOLC C (adjusted hazard ratio [aHR], 1.09 [95% CI, 1.05 to 1.13]) and D (aHR, 1.13 [95% CI, 1.09 to 1.18]) areas had worse OS, including 13% and 20% excess risk of death for individuals diagnosed with early- and 6% and 8% for late-stage disease for HOLC C and D, respectively.

CONCLUSION

Historical housing discrimination is associated with worse contemporary access to colon cancer care and outcomes.

Financial Toxicity and Quality of Life in Patients Undergoing Stem-Cell Transplant Evaluation: A Single-Center Analysis

PURPOSE

We investigated the prevalence of financial toxicity in a population undergoing hematopoietic cell transplantation (HCT) evaluation and measured its impact on post-transplant clinical and health-related quality-of-life outcomes.

MATERIALS AND METHODS

This was a prospective study in patients undergoing evaluation for allogeneic HCT between January 1, 2018, and September 23, 2020, at a large academic medical center. Financial health was measured via a baseline survey and the comprehensive score for financial toxicity-functional assessment of chronic illness therapy (COST-FACIT) survey. The cohort was divided into three groups: none (grade 0), mild (grade 1), and moderate-high financial toxicity (grades 2-3). Health-related quality of life outcomes were measured at multiple time points. Multivariate logistic regression analysis evaluated factors associated with financial toxicity. Kaplan-Meier curves and log-rank tests was used to evaluate overall survival (OS) and nonrelapse survival.

RESULTS

Of 245 patients evaluated for transplant, 176 (71.8%) completed both questionnaires (median age was 57 years, 63.1% were male, 72.2% were White, and 39.2% had myelodysplastic syndrome, 38.1% leukemia, and 13.6% lymphoma). At initial evaluation, 83 (47.2%) patients reported no financial toxicity, 51 (29.0%) with mild, and 42 (23.9%) with moderate-high financial toxicity. Patients with financial toxicity reported significant cost-cutting behaviors, including reduced spending on food or clothing, using their savings, or not filling a prescription because of costs (P < .0001). Quality of life was lower in patients with moderate-high financial toxicity at 6 months (P = .0007) and 1 year (P = .0075) after transplant. Older age (>62; odds ratio [OR], 0.33 [95% CI, 0.13 to 0.79]; P = .04) and income ≥$60,000 in US dollars (USD) (OR, 0.17 [95% CI, 0.08 to 0.38]; P < .0001) were associated with lower odds of financial toxicity. No association was noted between financial toxicity and selection for transplant, OS, or nonrelapse mortality.

CONCLUSION

Financial toxicity was highly correlated with patient-reported changes in compensatory behavior, with notable impact on patient quality of life after transplant.

Association of area-level mortgage denial and guideline-concordant non-small-cell lung cancer care and outcomes in the United States

BACKGROUND

Racial and socioeconomic disparities in receipt of care for non-small-cell lung cancer (NSCLC) are well described. However, no previous studies have evaluated the association between mortgage denial rates and receipt of timely and guideline-concordant care for NSCLC and patient outcomes.

METHODS

We identified individuals ≥18 years diagnosed with NSCLC between 2014 and 2019 from the National Cancer Database. Using the Home Mortgage Disclosure Act database, we calculated the proportion of denied home loans to total loans at the zip-code level and categorized them into quintiles. Our outcomes included receipt of guideline-concordant care based on clinical and pathologic stage at diagnosis and the National Comprehensive Cancer Network guidelines, time from surgery to chemotherapy initiation, and overall survival.

RESULTS

Of the 629,288 individuals diagnosed with NSCLC (median age 69; IQR 61-76 years, 49.1% female), 47.8% did not receive guideline-concordant care. Residing in areas with higher mortgage denial rates and lower income was associated with worse guideline-concordant care overall (aRR = 1.28; 95% CI = 1.25-1.32) and for each cancer treatment modality, worse receipt of timely chemotherapy (aHR = 1.14; 95% CI = 1.11-1.17) and worse overall survival (aHR = 1.21; 95% CI = 1.19-1.22), compared with residing in areas with the lowest mortgage denial rate and highest income.

CONCLUSIONS

Area-level mortgage denial rate was associated with worse receipt of timely and guideline-concordant NSCLC care and survival. This highlights the critical need to understand and address systemic practices, such as mortgage denial, that limit access to resources and are associated with worse access to quality cancer care and outcomes.

Local Social Vulnerability as a Predictor for Cancer-Related Mortality Among US Counties

Substantial gaps in national healthcare spending and disparities in cancer mortality rates are noted across counties in the US. In this cross-sectional analysis, we investigated whether differences in local county-level social vulnerability impacts cancer-related mortality. We linked county-level age-adjusted mortality rates (AAMR) from the Centers for Disease Control and Prevention (CDC) Wide-ranging Online Data for Epidemiologic Research database, to county-level Social Vulnerability Index (SVI) from the CDC Agency for Toxic Substances and Disease Registry. SVI is a metric comprising 15 social factors including socioeconomic status, household composition and disability, minority status and language, and housing type and transportation. AAMRs were compared between least and most vulnerable counties using robust linear regression models. There were 4 107 273 deaths with an overall AAMR of 173 per 100 000 individuals. Highest AAMRs were noted in older adults, men, non-Hispanic Black individuals, and rural and Southern counties. Highest mortality risk increases between least and most vulnerable counties were noted in Southern and rural counties, individuals aged 45-65, and lung and colorectal cancers, suggesting that these groups may face highest risk for health inequity. These findings inform ongoing deliberations in public health policy at the state and federal level and encourage increased investment into socially disadvantaged counties.

Trends in the Prevalence of Functional Limitations Among US Cancer Survivors, 1999-2018

This cross-sectional study examines trends in the prevalence of functional limitation in cancer survivors using data from the National Health Interview Survey.

Prevalence of Delayed or Forgone Care Due to Patient-Clinician Identity Discordance Among US Cancer Survivors

This case-control study assesses the prevalence of patient-reported delayed or forgone care due to patient-clinician identity discordance among cancer survivors and factors associated with this barrier to care.

Incorporating Cost Measures Into the Merit-Based Incentive Payment System: Implications for Oncologists

PURPOSE

The Merit-Based Incentive Payment System (MIPS) is currently the only federally mandated value-based payment model for oncologists. The weight of cost measures in MIPS has increased from 0% in 2017 to 30% in 2022. Given that cost measures are specialty-agnostic, specialties with greater costs of care such as oncology may be unfairly affected. We investigated the implications of incorporating cost measures into MIPS on physician reimbursements for oncologists and other physicians.

METHODS

We evaluated physicians scored on cost and quality in the 2018 MIPS using the Doctors and Clinicians database. We used multivariable Tobit regression to identify physician-level factors associated with cost and quality scores. We simulated composite MIPS scores and payment adjustments by applying the 2022 cost-quality weights to the 2018 category scores and compared changes across specialties.

RESULTS

Of 168,098 identified MIPS-participating physicians, 5,942 (3.5%) were oncologists. Oncologists had the lowest cost scores compared with other specialties (adjusted mean score, 58.4 for oncologists v 71.0 for nononcologists; difference, -12.66 [95% CI, -13.34 to -11.99]), while quality scores were similar (82.9 v 84.2; difference, -1.31 [95% CI, -2.65 to 0.03]). After the 2022 cost-quality reweighting, oncologists would receive a 4.3-point (95% CI, 4.58 to 4.04) reduction in composite MIPS scores, corresponding to a four-fold increase in magnitude of physician penalties ($4,233.41 US dollars [USD] in 2018 v $18,531.06 USD in 2022) and greater reduction in exceptional payment bonuses compared with physicians in other specialties (-42.8% [95% CI, -44.1 to -41.5] for oncologists v -23.6% [95% CI, -23.8 to -23.4] for others).

CONCLUSION

Oncologists will likely be disproportionally penalized after the incorporation of cost measures into MIPS. Specialty-specific recalibration of cost measures is needed to ensure that policy efforts to promote value-based care do not compromise health care quality and outcomes.

Oncologist Participation and Performance in the Merit-Based Incentive Payment System

The merit-based incentive payment system (MIPS) is a value-based payment model created by the Centers for Medicare & Medicaid Services (CMS) to promote high-value care through performance-based adjustments of Medicare reimbursements. In this cross-sectional study, we examined the participation and performance of oncologists in the 2019 MIPS. Oncologist participation was low (86%) compared to all-specialty participation (97%). After adjusting for practice characteristics, higher MIPS scores were observed among oncologists with alternative payment models (APMs) as their filing source (mean score, 91 for APMs vs. 77.6 for individuals; difference, 13.41 [95% CI, 12.21, 14.6]), indicating the importance of greater organizational resources for participants. Lower scores were associated with greater patient complexity (mean score, 83.4 for highest quintile vs. 84.9 for lowest quintile, difference, -1.43 [95% CI, -2.48, -0.37]), suggesting the need for better risk-adjustment by CMS. Our findings may guide future efforts to improve oncologist engagement in MIPS.

Food insecurity and gastrointestinal (GI) cancer mortality in the United States, 2015 to 2019

788

Background: Food insecurity is a crucial but under-appreciated social determinant of health in GI cancers given high rates of cachexia where nutritional status may adversely impact functional status and outcomes. We investigated the impact of county-level food insecurity on age-adjusted mortality rates (AAMRs) from GI cancer. Methods: GI cancer-related deaths (ICD C15-26) were linked across US counties from 2015-2019 in the CDC WONDER database to county-level food insecurity measures from Feeding America and Census County Business Patterns databases. These included percent of individuals with food insecurity or on Supplemental Nutrition Assistance Program (SNAP) benefits, and the average cost/meal (USD) and density of local fast food/take-out restaurants. All measures were classified into quartiles based on distribution. AAMRs per 100,000 were compared between 1st and 4th quartiles for each measure using robust linear regression models with log scale and including the population size as weights. Results: There were 790,624 GI cancer deaths with overall AAMR 43.0 (68.5% age >65y, 57.8% male, 12.9% non-Hispanic Black, 8.9% Hispanic, 82.4% urban, 33.6% colorectal, 27.7% pancreatic, 19.6% liver/biliary cancer). Highest AAMRs were noted for age >65y, men, non-Hispanic White, and rural areas. AAMRs increased when moving from least to most insecure counties as defined by overall food insecurity, higher proportion of population on SNAP, or by higher local fast food density. AAMRs were lower in counties where cost per meal was higher. Association between AAMRs and all measures were strongest in younger adults (<65y), men, and rural counties, while association between AAMR and fast food density was strong among non-Hispanic Black individuals. Conclusions: Our study highlights the most food insecure US counties also have higher GI cancer mortality with significant sociodemographic variation. Food insecurity may be a helpful proxy for county-level social vulnerability in driving GI cancer mortality. Our findings recognize an important relationship between nutrition and cancer mortality and should inform ongoing congressional policy on food insecurity and assistance.[Table: see text]

Demographic and regional trends of gastrointestinal (GI) cancer mortality in adolescents and young adults (AYA) in the US, 1999-2019

786

Background: There is an alarming rise in incidence of GI cancers in AYAs that face unique social challenges in navigating their healthcare and receiving guideline-concordant care. There is limited data on mortality trends in this understudied group. We investigated age-adjusted mortality rates (AAMRs) in young adults with GI cancer. Methods: We utilized the CDC WONDER database to analyze deaths among young adults aged 15 to 44 years from GI cancer (ICD 15-26) from 1999 to 2019. We calculated AAMRs per 100,000 and stratified by sex, race/ethnicity, census, and urban metro (population >1,00,000), medium/small (50,000 – 999,999) or rural area (<50,000) per NCHS Classification Scheme. We used Joinpoint regression software (v4.9) to establish annual percentage change (APC) trends. Results: Between 1999 and 2019, there were 73,954 deaths from GI cancer in young adults (39% female, 16% Hispanic, 20% non-Hispanic Black, 16% rural, 42% Southern-located, 52% colorectal, and 17% each pancreatic, hepatobiliary, and gastric cancers). Overall AAMR over study period was 3.3. Among subgroups, the AAMR was higher in men (3.9), non-Hispanic Black adults (4.6), and rural areas (3.7). Time analysis by year showed overall stability or slight decrease in AAMRs between 1999-2009, followed by an increase from 2009-2019. This was especially notable in Hispanic individuals. Earlier increases in AAMR were noted in rural (since 2004) and Midwestern (since 2001) locations. Highest AAMRs were noted in Southern states (Mississippi, Kentucky, West Virginia, and Alabama). Compared to our younger cohort, older adults (45+) had expectedly higher but recorded significantly better AAMR improvements during study period. Conclusions: Mortality rates for AYAs with GI cancers remained relatively stable from 1999 to 2009, but have since risen, with significant sociodemographic and regional variation. These data highlight the need to better understand risk factors (diet, environmental, and other), screening trends, and variation in receipt of guideline-concordant care to ensure appropriate and equitable risk reduction and cancer management in AYAs.[Table: see text]

Housing and Cancer Care and Outcomes: A Systematic Review

BACKGROUND

Access to stable and affordable housing is an important social determinant of health in the United States. However, research addressing housing and cancer care, diagnosis, and outcomes has not been synthesized.

METHODS

We conducted a systematic review of studies examining associations of housing and cancer care and outcomes using PubMed, Embase, Scopus, and CINAHL. Included studies were conducted in the United States and published in English between 1980 and 2021. Study characteristics and key findings were abstracted and qualitatively synthesized.

RESULTS

A total of 31 studies were identified. Housing-related measures were reported at the individual level in 20 studies (65%) and area level in 11 studies (35%). Study populations and housing measures were heterogeneous. The most common housing measures were area-level housing discrimination (8 studies, 26%), individual-level housing status (8 studies, 26%), and individual-level housing concerns (7 studies, 23%). The most common cancer outcomes were screening (12 studies, 39%) and mortality (9 studies, 29%). Few studies assessed multiple dimensions of housing. Most studies found that exposure to housing insecurity was statistically significantly associated with worse cancer care (11 studies) or outcomes (10 studies).

CONCLUSIONS

Housing insecurity is adversely associated with cancer care and outcomes, underscoring the importance of screening for housing needs and supporting systemic changes to advance equitable access to care. Additional research is needed to develop and test provider- and policy-level housing interventions that can effectively address the needs of individuals throughout the cancer care continuum.

Impact of proposed 2022 changes to the Merit-Based Incentive Payment System (MIPS) on oncologist performance and reimbursement

6

Background: In 2017, the Centers for Medicare & Medicaid Services (CMS) executed a landmark bipartisan legislation aimed at gradually shifting American healthcare from a fee-for-service model to a value-based system. The resulting payment model, MIPS, uses cost and quality metrics to assign clinicians an overall MIPS score, where higher scores correspond to greater payments for practices. In 2018, cost metrics contributed only 10% of this composite score, while quality metrics contributed 50%. Beginning with 2022, the cost and quality categories will be equally weighted (30% each) to encourage clinicians to reduce healthcare costs. As the cost of cancer care is disproportionately high, we investigated the implications of the updated scoring on reimbursements for oncologists and other providers participating in MIPS. Methods: We included physicians participating in the 2018 MIPS Performance Year files. We categorized hematological-, medical, radiation, gynecological, and surgical oncologists as oncologists and delineated those with National Cancer Institute-designated Cancer Center (NCICC)-affiliation. We excluded individuals who were exempt from reporting cost scores due to their MIPS-filing method. We calculated the projected 2022 MIPS composite scores (range, 0-100) by multiplying the 2022 weights by the 2018 component scores. We compared the change in composite MIPS score and the corresponding negative payment adjustments due to reweighing across specialties. Clopper–Pearson 95% confidence intervals were reported. Results: The cohort included 168,659 physicians, of which 163,150 (97%) were non-oncologists and 5,509 (3%) were oncologists. Of oncologists, 1,757 (32%) were at a NCICC. Cost scores (higher is better) for each group were as follows: non-oncologists, 75.2; all oncologists, 65.5; NCICC oncologists, 57.1. Reweighing the 2018 MIPS composite scores with the updated 2022 cost/quality weights resulted in a mean 1.7-point decrease (88.7 to 87) for non-oncologists, a 3.8-point decrease (89.7 to 85.9) for all oncologists, and a 5.2-point decrease (89.2 to 84) for NCICC oncologists. Following the reweighing, the proportion of non-oncologists incurring penalties will increase by 12.8% (95% CI, 12.7%–12.9%); all oncologists by 14.3% (95% CI, 13.2%–15.4%); and NCICC oncologists by 20% (95% CI, 18.1%–21.9%). Conclusions: Beginning with 2022 performance year, federally mandated reweighing of MIPS cost metrics will result in a disproportionate increase in oncologists receiving negative payment adjustments. With a majority Medicare population with new cancer diagnoses, higher patient complexity, and declining operating margins at many oncologic practices, we highlight striking upcoming changes that may inform further optimization of MIPS cost metrics by CMS to ensure oncologists providing high quality care are not penalized.

Innovation in recruitment and curricular design for diversity, equity, and inclusion (DEI) education for hematology-oncology (HO) trainees

179

Background: Alongside persistent disparities in healthcare outcomes in HO, there is an inability to adequately recruit, maintain and promote a diverse and inclusive work force nationwide. To our knowledge, a structured approach to DEI education/recruitment in HO training is lacking. We sought to establish a longitudinal curriculum aimed at educating HO trainees in structural barriers impacting cancer equity and developing tools to enhance Underrepresented in Medicine (URiM) recruitment. Methods: Trainee-led DEI framework was presented to program leadership and officially adopted into the curriculum for the 2021-22 academic year. This consisted of initiatives across 4 domains: 1. Curricular Development (emphasis on disparities during trainee orientation, didactic lectures on cancer disparities, financial toxicity, workforce diversity, pandemic impact on cancer inequities) ; 2. Recruitment & Retention (implicit bias training, targeted recruitment from HBCUs, trainee-led discussions on enhancing recruitment); 3. Engagement & Mentorship (local community mentorship within institution, external mentorship through ASCO URM MSR program); 4. Disparities Research (career guidance sessions with invited faculty, development of registry-based studies to evaluate disparities). Impact of new curriculum was measured through anonymous surveys, at 1, 7, and 12 months during the academic year. A 5-point Likert scale (strongly disagree to strongly agree) was utilized. Results: At baseline, surveyed trainees were predominantly PGY5 (33%), ages 31-40 (66%), and self-identified as White or Caucasian (47%). Over the academic year, trainee recognition of structural barriers that prevented oncologic care delivery increased. More trainees felt departmental/fellowship-wide DEI efforts were transparent and impactful leading to quantifiable changes, and creation of new mentorship opportunities. Trainees rated the following as most helpful to address biases in the workplace: opportunities to mentor minority high school/college-level students, implicit bias training, and formal lectures. Anonymous qualitative feedback from fellows favored small group discussions and encouraged a top-down approach to promoting diversity in leadership. One trainee-mentored URiM medical student presented work at the ASCO annual conference on cancer disparities, while program leadership efforts led to incoming trainee class comprised of 25% URiM. Conclusions: We demonstrate feasibility of a longitudinal DEI curriculum in HO trainee education and recruitment that raises awareness and creates opportunity for URiM. Future efforts will build on this curriculum utilizing trainee feedback and departmental buy-in with the goal of building an oncologic workforce that better reflects the patients we care for.

Geographic disparities in head and neck cancer mortality and place of death in the United States from 2003 to 2019

161

Background: Survival has significantly improved for patients with head and neck cancer (HNC) in the last decade in the US. Unfortunately, social determinants of health continue to impact patient outcomes. HPV vaccine uptake and access to quality end-of-life care vary notably between geographic areas. We investigated potential disparities in rural-urban age-adjusted mortality rates (AAMRs) and place of death for individuals with head and neck cancer (HNC). Methods: We used the CDC WONDER database to identify patients who died from HNC between 2003 and 2019 within the following 2013 US Census population classifications: large metropolitan (≥1 million), medium/small metropolitan (50,000-999,999), and rural areas (< 50,000). AAMR (per 100,000 individuals) was stratified by geographic area, age, and race/ethnicity. Annual percentage changes (APC) in AAMR were estimated with linear regression models of the log-scale AAMR (including population size as weights) and differential changes over time by geographic area were assessed with interaction tests. Odds ratios (OR) for the association between each place of death and individual-level characteristics were calculated using logistic regression, adjusting for year of death. Results: From 2003 to 2019, 221,861 deaths related to HNC occurred (48.5% large metropolitan, 31.9% medium/small metropolitan, 19.7% rural). Total AAMR declined from 6.7 to 5.8 during this period. Rural areas consistently had a higher AAMR and also slower annual improvement over time (APC –0.11; 95% CI, –0.36 to 0.13; p < 0.001) than medium/small metropolitan (APC –0.51; 95% CI, –0.78 to 0.24) and large metropolitan areas (APC –1.19; 95% CI, –1.39 to –1.0; p < 0.001). Non-Hispanic (NH) Black patients had the highest overall AAMR, but quickest annual improvement (APC –2.91; 95% CI, –3.28 to –2.55; p < 0.001) compared to Hispanic (APC -1.42, 95% CI, -1.9 to -0.93) and NH White patients (APC –0.26, 95% CI, –0.44 to 0.07). Individuals in rural areas died less often in a hospice facility (5.6% rural vs 10.8% large metropolitan vs 12% medium/small metropolitan) and slightly more often at home (46.3% rural vs 40.1% large metropolitan vs 43.7% medium/small metropolitan). Relative to patients in rural areas, patients in large metropolitan (OR 1.77; 95% CI, 1.74 to 1.81) and medium/small metropolitan areas (OR 2.27; 95% CI, 2.23 to 2.31) had higher odds of dying in a hospice facility compared to a medical facility. Conclusions: Rural residents with HNC experienced higher mortality rates and had lesser improvement compared to urban areas, with notable sociodemographic differences, and disparities in place of death. Public health interventions to combat health inequities for patients with HNC are required. Further, as EOL care is increasingly complex and the role of unpaid caregiving burdensome, policy interventions targeted to support disadvantaged populations and communities are urgent and necessary.

Out-of-pocket costs for oral anticancer drugs

14

Background: Oral anticancer drug annual out-of-pocket costs (OOPCs) for Medicare beneficiaries are frequently > $10,000. Many of these medications are available as multiple formulations (e.g., tablet/capsule) and multiple strengths (e.g., 25mg/50mg). Oral medications are typically priced per unit (pill), allowing for more cost-effective prescribing when patients use fewer pills to obtain a recommended dose. It is unclear whether cancer drugs follow this traditional paradigm. We sought to assess the relationship between drug formulation features and OOPCs. Methods: We included 20 oral anticancer drugs with the highest spending in Medicare Part D in 2020. For each drug, we identified formulations, strengths, and schedules using NCCN guidelines and UptoDate. For each product, we calculated a lowest expected annual drug OOPC for all relevant strengths/schedules using the 2022 Part D Plan Finder. For example, the drug osimertinib is available in 40 and 80 mg tablets, with total daily doses of 80 and 160mg, reflecting 4 pricing scenarios. We assessed costs for 1 year of monthly fills. We compared cost ratios across formulations for each drug. Results: Of the 20 drugs, 17 (85%) were available as brand-name only; 3 (15%) were also available as generic. Fifteen (75%) were available as a single formulation only (e.g., tablet only); 5 (25%) were available as multiple formulations (e.g., tablet and capsule). Eighteen (90%) were available in multiple strengths. Median annual drug OOPCs was $12,979. For brand vs generic comparisons (n = 4, keeping other variables constant, 1 drug could have > 1 comparison due to different strengths), brand coverage for imatinib and 250 mg abiraterone tablets was limited, leading to high cost ratios (brand/generic > 50). For 2 other comparisons, the brand was less costly (abiraterone 500 mg tablets, ratio 0.85) and more costly (everolimus 10 mg tablets, ratio 1.18) for 1 each. For tablet vs capsules/others (n = 4), tablets were cheaper for 2 (ratio, 0.63- 0.96), a little more costly for 1 (ratio 1.04), and a lot more costly for 1 (ratio 2.13, ibrutinib 140 mg). For comparisons across strengths of the same formulation to achieve the same total dose (n = 14), using lower strength/higher fill quantity was more costly for 10 drugs (median ratio 1.79), the same for 1, and less costly for 3 (ratios 0.35- 0.89). Conclusions: Even when considering the least costly Part D plan, 2022 oral anticancer drug OOPCs remain high. Counter to expectations, in some cases generics were more costly than brands, and more pills at a lower dose were less costly than fewer pills. There was no consistent pattern. Oncologists and pharmacists cannot be expected to know the unpredictable OOPC ramifications of biologically equivalent prescription decisions. As cancer primarily affects older adults, often living on fixed incomes, policy-level change to lower OOPCs are necessary to avoid financial ruin and enhance access for Medicare beneficiaries.

Social vulnerability and cancer-related mortality among U.S. counties, 2013 to 2019

162

Background: Substantial differences exist among US counties with regards to cancer-related mortality. Social determinants of health (SDOH) can predispose underserved communities to poor cancer outcomes. We investigated the impact of county-level social vulnerability on age-adjusted cancer mortality rates (AAMRs). Methods: We linked cancer-related deaths across US counties from 2013 to 2019 in the CDC WONDER database to county-level Social Vulnerability Index (SVI) data from the CDC/ATSDR. Scores for overall SVI and its 4 subcomponents (socioeconomic status; household composition and disability; minority status and language; housing type and transportation) were calculated using 15 SDOH attributes. These were presented as percentile rankings by county and classified into quartiles based on their distribution among US counties (1st [least vulnerable] = 0 - 0.25; 4th [most vulnerable = 0.75 - 1.00]). AAMRs per 100,000 individuals across US counties were compared between 1st and 4th SVI quartiles using robust linear regression models with a log scale. Results: There were 4,107,273 deaths with overall AAMR 173 per 100,000 individuals. Highest AAMRs were noted among older adults > 65 years, men, non-Hispanic Black, and rural counties. AAMRs increased proportionally when moving from least to most vulnerable counties. Counties in 4th SVI quartile had 20% higher AAMRs compared to 1st SVI quartile (rate ratio; RR 1.08, 95% CI [1.08, 1.09], p < 0.001). This was pronounced for ages 45-65 (42% increase; RR 1.21, 95% CI [1.12 – 1.24]), Hispanic race (26% increase; RR 1.11, 95% CI [1.06, 1.16]), and rural counties (21% increase; RR 1.17, 95% CI [1.15, 1.19]). Increase in AAMR between 1st and 4th SVI quartile from vulnerable socioeconomic status was most pronounced in rural counties (RR 1.17; 95% CI [1.15, 1.2]), women (RR 1.17; 95% CI [1.15, 1.2]) and ages 45-65 (RR 1.15; 95% CI [1.09, 1.14]). Vulnerable household composition/disability was most pronounced for rural residents (RR 1.12; 95% CI [1.09, 1.14]), and housing/transportation barriers for Hispanic individuals (RR 1.15; 95% CI [1.09, 1.21]). Conclusions: This study highlights the most socially vulnerable US counties have higher cancer mortality rates than the least vulnerable US counties. Furthermore, non-Hispanic blacks, older adults, and rural counties face highest risks of health inequities. Our findings inform ongoing congressional deliberations on transportation, telehealth, and rural infrastructure to achieve geographic parity.[Table: see text]

Association of area-level mortgage discrimination and guideline-concordant non–small cell lung cancer care in the United States

3

Background: Disparities in receipt of care for non-small cell lung cancer (NSCLC) are well described. Discriminatory mortgage lending, which limits access to home ownership in specific neighborhoods overall and disproportionately for racialized groups, is a marker of systemic racism and lower levels of neighborhood investment. This may, in turn, decrease access to high quality care. We used the mortgage denial rate as a measure of housing discrimination and investigated its association with guideline-concordant NSCLC care. Methods: Mortgage denial rates were estimated at the zip code tabulation areas (ZCTAs) level using the Home Mortgage Disclosure Act (HMDA) database (2014-2019). Mortgage denial rates represent the proportion of denied home loans to total loans and were categorized into quartiles. Individuals ≥ 18 years diagnosed with NSCLC 2014-2019 were identified from the National Cancer Database and combined with HMDA. Multivariable logistic regression models examined associations between mortgage discrimination and receipt of guideline-concordant care, including surgery, chemotherapy, and chemoradiation. A multivariable Cox proportional hazard model examined the association between mortgage discrimination and time to chemotherapy initiation. Results: Cohort included 450,614 patients newly diagnosed with NSCLC resided in 33,120 ZCTAs. Individuals residing in ZCTAs with higher mortgage denial rates were more likely to be aged 45-64 years, male, non-Hispanic White, with private health insurance coverage and income < $40,000/year. 69% of all patients received guideline-concordant care. Likelihood of guideline-concordant care was lower in neighborhoods with higher mortgage denial rates, adjusting for age and sex (Table). This disparity was present in all care subgroups. Time to chemotherapy initiation was longer for patients in neighborhoods with higher mortgage denial rates. Conclusions: Mortgage discrimination is adversely associated with receipt of guideline-concordant NSCLC care. Our examination of institutional practices leading to barriers in access to resources highlights the critical need to understand the pathways through which area-level mortgage denials impact receipt of equitable cancer care.[Table: see text]

Disparities in place of death from prostate cancer revealed by disaggregation of Asian race

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Background: Place of death (PoD) is a surrogate determinant of health care inequity in patients with cancer. Aggregation of Asian Americans, a diverse group, may mask significant health disparities in end-of-life care. Methods: De-identified death certificate data were obtained via the National Center for Health Statistics. All adult (> 18 years of age) prostate cancer deaths from 2018 to 2019 were included. Multinomial logistic regression was used to test for differences in place of death associated with sociodemographic variables. Results: From 2018 through 2019, 81,292 adults died from prostate cancer. Overall, most Asians were less likely to die at home (p < 0.05) or nursing facility (p < 0.05) compared to White patients. Significant differences in nursing facility use was noted in disaggregated analysis, with Samoan patients 12.44 times more likely to die in a hospice facility compared to hospital (CI 2.89, 53.6; p < 0.001) and Chinese patients 100 times less likely to die in a hospice facility (CI 0.01, 0.02; p < 0.001) to give two notable examples. Chinese (OR 0.26), Guamanian (OR 0.2), and Vietnamese race (OR 0.05) had the lowest likelihood of dying at home, with odds ratio lower than Black race (OR 0.3) (Table). Conclusions: Increased attention to PoD over recent years has highlighted issues around equity in end-of-life care. Overall, our data underscore important differences among Asian subpopulations and possible barriers to quality end of life care that would otherwise be masked with data aggregation. It is well known that resources are needed to allow death at home or at a nursing facility. Further qualitative work is planned to investigate culture differences contributing to PoD differences for patients with cancer through the lens of the social determinants of health.

Price variability of pembrolizumab across U.S. National Cancer Institute–designated Cancer Centers (NCICCs) from 2016-2021

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Background: NCICCs are poorly compliant to price transparency rules set forth by the CMS. Competitive price shopping is prevented due to a lack of uniform rate setting, and service charges are often higher than what a hospital reasonably expects to be reimbursed. We investigated variability in the charged and reimbursed payments for pembrolizumab utilizing Medicare claims across all NCICCs. Methods: Medicare claims data from 2016-2021 for pembrolizumab (HCPCS J9271) infusions in a hospital outpatient department were selected from the Definitive Healthcare claims database for all hematology-oncology and medical oncology providers at NCICCs. Average charges, reimbursements, and total claims were obtained. Annual percentage changes (APC) were calculated to evaluate trends during study period. Prices are presented as inflation adjusted numbers (charged and reimbursed; 2021 dollars). Analyses were performed in Excel (Microsoft Corp). Results: Our analysis included 53 NCICCs of which 47 were part of the 340B Drug Pricing Program (NCI-340B), 11 were Prospective Payment System-exempt (NCI-PPS), and 6 NCICCs were both (PPS/340B). From 2016 to 2021, total Medicare claims increased from 9461 to 46291 across NCICCs, with NCI-PPS centers comprising 30% of claims. Total payments to NCICCs increased from $55.9M to $388.1M annually. Average charge for pembrolizumab in 2021 were: $45,227 (NCI-PPS), $46,000 (all NCICCs), $49,057 (NCI-340B), $59,392 (dual-eligible PPS/340B). During study period, APC were: 9.2% (NCICCs), 9.6% (NCI-340B), 12.8% (NCI-PPS), and 17.5% (dual-eligible PPS/340B). Despite high charged prices, reimbursement was much lower, about 18.4% (or $7364) of charged price at NCICCs over study period. Highest reimbursement was noted at NCI-PPS (22%, or $8551), and lowest at NCI-340B (16.4% or $7086) over study period. When considering a smaller cohort of PPS-only or 340B-only, PPS-only status was associated with lowest charged price but highest reimbursement (33.5%, or $8568). Conclusions: NCICCs charged > 4 times the average reimbursed price for pembrolizumab, with charges increasing faster than inflation. While lower charges were noted at NCI-PPS, they received higher reimbursement. Dual PPS/340B status commanded the highest charged prices and quickest price increases. Our study informs greater price transparency regulation at NCICCs and raises questions regarding utility of special status benefits from the federal government.[Table: see text]

Association of historical housing discrimination and colon cancer treatment and outcomes in the United States

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Background: In the 1930s, the federally-sponsored Home Owners’ Loan Corporation (HOLC) created maps that directed mortgage financing based largely on a neighborhood’s racial composition. American neighborhoods were subdivided into four risk-based rankings (A – best neighborhood, B – still desirable, C – in decline, and D – hazardous and mapped in red) for mortgage approvals and denials. “Redlining” resulted in racial segregation and systemic disinvestment in communities targeted for marginalization. We investigated the association between historical housing discrimination and contemporary diagnosis, treatment, and survival outcomes in colon cancer – a leading cause of cancer deaths amenable to early detection and treatment. Methods: Individuals diagnosed with colon cancer from 2007-2017 were identified from the National Cancer Database. Individuals residing within known zip code tabulation areas (ZCTA) in 196 cities with ≥10% HOLC coverage were included. Residences were assigned a HOLC grade (A, B, C, or D) based on the majority HOLC area represented. Multivariable logistic regression models (adjusted for age and sex) were used to investigate the association of housing discrimination and late stage (stages III/IV) diagnosis, time to chemotherapy initiation, and non-guideline-concordant care (no chemotherapy, surgery, or < 12 lymph node dissection). Multivariable Cox proportional hazard models with age as time scale were used to investigate the association of housing discrimination and overall survival. Results: There were 98,335 patients with new diagnoses of colon cancer with median age 68 years. Individuals residing in HOLC D were more likely to be non-Hispanic White (59%), have public insurance (46%), and income < $40,000/year. Compared to people living in majority HOLC A ZCTAs, living in majority HOLC D had higher odds of a late-stage diagnosis, and living in majority HOLC B, C, or D had higher odds of non-guideline concordant colon cancer care with longer time to chemotherapy initiation. For people living in majority HOLC C and D, overall survival for all stages and late stage was worse when compared to HOLC A ZCTAs. Findings were consistent in sensitivity analysis. Conclusions: Historical housing discrimination is adversely associated with contemporary colon cancer care and outcomes. Findings underscore the importance of state-and federal-level practices on mortgage lending regulation and fair housing practices in determining equitable cancer risk, access to care, and outcomes.[Table: see text]

Intermediate Strengths and Inflated Prices: The Story of Transdermal Fentanyl Patches

In 2015, Mylan pharmaceuticals received final approval from the Food and Drug Administration for its Supplemental Abbreviated New Drug Application and introduced three new intermediate strengths of transdermal fentanyl patches to the U.S. drug market.¹ With this approval, Mylan added 37.5 , 62.5, and 87.5 mcg/hr strength patches to existing 12, 25, 50, 75, and 100 mcg/hr strength patches. Today, these intermediate strength patches cost many times more than older strengths. In this commentary, we discuss the clinical implications of intermediate strengths of the fentanyl patch, explore mechanisms for price differences, and offer practice-based and policy solutions to address these differences.

Utilization of Filgrastim and Infliximab Biosimilar Products in Medicare Part D, 2015-2019

This cross-sectional study examines utilization trends for filgrastim and infliximab products and their biosimilars to understand whether biosimilars are associated with reduced spending in Medicare Part D.

Does Cancer Treatment-Related Financial Distress Worsen Over Time?

BACKGROUND Patients with cancer are at risk for both objective and subjective financial distress. Financial distress during treatment is adversely associated with physical and mental well-being. Little is known about whether patients' subjective financial distress changes during the course of their treatment.method This is a cross-sectional study of insured adults with solid tumors on anti-cancer therapy for ≥1 month, surveyed at a referral center and three rural oncology clinics. The goal was to investigate how financial distress varies depending on where patients are in the course of cancer therapy. Financial distress (FD) was assessed via a validated measure; out-of-pocket (OOP) costs were estimated and medical records were reviewed for disease/treatment data. Logistic regression was used to evaluate the potential association between treatment length and financial distress.RESULTS Among 300 participants (86% response rate), median age was 60 years (range 27-91), 52.3% were male, 78.3% had stage IV cancer or metastatic recurrence, 36.7% were retired, and 56% had private insurance. Median income was $60,000/year and median OOP costs including insurance premiums were $592/month. Median FD score (7.4/10, SD 2.5) corresponded to low FD with 16.3% reporting high/overwhelming distress. Treatment duration was not associated with the odds of experiencing high/overwhelming FD in single-predictor (OR = 1.01, CI [.93, 1.09], P = .86) or multiple predictor regression models (OR = .98, CI [.86, 1.12], P = .79). Treatment duration was not correlated with FD as a continuous variable (P = .92).LIMITATIONS This study is limited by its cross-sectional design and generalizability to patients with early-stage cancer and those being treated outside of a major referral center.CONCLUSION Severity of cancer treatment-related financial distress did not correlate with time on treatment, indicating that patients are at risk for FD throughout the treatment continuum. Screening for and addressing financial distress should occur throughout the course of cancer therapy.