Medicaid Patients With NSCLC May Be Undertreated With Life-prolonging Targeted Therapies


In the United States, 91% of states had lower rates of targeted therapy use than expected.

EFGR- and ALK-targeted therapies were indicated for 3641 person-years– an expression of incidence rate, or the amount of time a person recieves treatment– in patients with non–small cell lung cancer (NSCLC) in 2020 and 2021. However, an estimated 855 person-years of life were lost from lack of prescribed treatment using these therapies, according to a investigators who published their study in JAMA Network Open.

“We found evidence of underuse of targeted therapies for NSCLC among Medicaid beneficiaries and substantial variation in use of these efficacious medications across states,” investigators wrote in a recent article. “The association between the observed variation and states’ Medicaid access scores suggests that state policies and characteristics are associated with use of these medications.”

The FDA has approved 8 target therapies for EGFR variants and ALK rearrangements, commonalterations of NSCLC. Common novel therapies like osimertinib and alectinib (EGFR- and ALK-targeted therapies, respectively) are standard of care first-line treatments, but they cost more than $150,000 per year.

State Medicaid programs have a fixed budget, and many have dealt with novel drug costs by limiting patient enrollment in Medicaid, services, and using exclusory management strategies. These strategies can include prescribing less novel treatments, making patients justify why they deserve treatment, and limiting access to subspecialist oncologists.

Investigators compared the number of person-years of EGFR- and ALK-targeted therapies given to Medicaid patients in every state against the treatment’s expected person-years in a cross-sectional study. They aimed to understand the number of Medicaid patients who use targeted therapies for metastatic NSCLC across different states, along with associated factors.

The findings showed that 91% of states had lower utilization rates for targeted therapies than experts expected, and only 66% of all Medicaid patients with EGFR- and ALK-altered metastatic cancer received targeted therapies (2281 person-years). “At least 500 Medicaid patients with a diagnosis of EGFR- or ALK-altered metastatic NSCLC during these years did not receive targeted therapy when indicated,” investigators wrote in the article.

The team identified that state gross domestic product (GDP) per capita was associated with a higher rate of targeted therapy. The possible link between treatment and wealth could be associated with other factors including equity, community resources, and smoking rates.

Investigators also found that prior authorization processes can also discourage therapy use if oncologists are not there to guide patients. Further, an area with a greater density of oncologists was associated with greater targeted treatment use, demonstrating more available oncologists may be associated with more access to life-prolonging medications.

The study includes limitations. First, the investigators did not find the exact number of 1) patients with EGFR- and ALK-altered metastatic NSCLC 2) patients who filled prescriptions for osimertinib and alectinib. Additionally, the team did not determine smoking rates, include other possible prescriptions, or include patients over the age of 64 years.

“Where underuse is confirmed, policy makers should examine prescribing programs and practices in states to ensure that patients who require these life-prolonging medications are able to access them,” wrote study authors in the article. “Modifying state Medicaid policies may provide opportunities to improve access to life-prolonging treatments.”


Roberts T, Kesselheim A, Avorn J, et al. Variation in Use of Lung Cancer Targeted Therapies Across State Medicaid Programs, 2020-2021. JAMA Netw Open. 2023;6(1):e2252562. doi:10.1001/jamanetworkopen.2022.52562

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