SOCIOECONOMIC AND DEMOGRAPHIC DISPARITIES IN ADMINISTRATION OF IMMUNOTHERAPY FOR ADVNACED UROTHELIAL CARCINOMA OF THE BLADDER

• Published in: Urologic oncology Vol. 42; pp. S29 - S30
• Main Authors: Holland, Levi, Bhanvadia, Raj R, Iftach, Jeff, Taylor, Jacob, Gaston, Kris, Lotan, Yair, Margulis, Vitaly, Woldu, Solomon, Bagrodia, Aditya
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 01-03-2024
• ISSN: 1078-1439; 1873-2496
• DOI: 10.1016/j.urolonc.2024.01.106

Immunotherapy drug combinations (IO) have been increasingly utilized in first line platinum ineligible and second line settings for locally advanced metastatic urothelial carcinoma of the bladder (UCB) since FDA approval of atezolizumab in 2016. Since then, multiple additional IO therapies have been approved which have resulted in improved survival outcomes, particularly among platinum-ineligible patients whose options are otherwise limited. Despite evidence of benefit, barriers to access to these advanced therapies exist creating inequities in the treatment of advanced UCB. We therefore investigated these potential disparities in the National Cancer Database (NCDB) specifically examining social, economic, and demographic factors associated with receipt of IO in patients with metastatic or locally advanced UCB.
We queried the National Cancer Database for patients with stage IV UCB diagnosed between 2017 and 2020. The year 2017 was chosen as the start date for analysis given FDA approval of atezolizumab happened midway through year 2016. Major exclusion criteria included non-urothelial histology (pure squamous, pure adenocarcinoma, small cell or neuroendocrine features), unknown cancer staging, and those with unknown systemic IO administration status. Our primary outcome of interest was odds of receiving IO therapy. We used multivariable logistic regression and adjusted for relevant socioeconomic and demographic variables. Variables analyzed included age, year of diagnosis, Charlson-Deyo score, sex, race, ethnicity, insurance status, educational level, median household income, residential setting, travel distance, facility location, academic hospital setting, and Medicaid expansion status.
10,380 patients with stage IV UCB met inclusion/exclusion criteria. Of these, 2,231 patients (21.5%);received IO therapy. On logistic regression, more recent diagnosis year (2020,OR:2.3,p<0.001), older age (Age >75, OR:1.5,p=0.002), moderate comorbidity (Charlson score=2,OR:1.2,p=0.03), highest income quartile (>$74,063,OR:1.3,p=0.009), education level (<5% Highschool diploma, OR:1.3,p=0.04), were associated with greater odds of receipt of IO. Presence of any insurance, with the exception of other governmental insurance was associated with greater odds of receipt of IO compared to no insurance. Treatment at a non-academic facility compared to treatment at an academic facility (OR:0.78,p<0.001) was associated with lower odds of IO therapy. Common demographic variables of race, ethnicity, and gender, did not impact receipt of IO. Further, states who participated in Medicaid expansion did not see an increased odds of receipt of IO.
In the era of FDA approved immunotherapy, this national cohort analysis suggests that although increased utilization of IO has occurred over time, significant disparities exist based on personal finances, education level, and insurance status. Non-academic facilities were also less likely to administer IO therapy. Surprisingly, common known disparities in relation to oncologic outcomes such as race, gender, Hispanic ethnicity, and rural location were not associated with disparities in receipt of IO therapy, possibly suggesting some decreases in gaps of care for metastatic UCB. Limitations of this analysis include lack of granularity in assessing receipt of specific immunotherapies which limits our ability to draw conclusions on specific therapies or therapy combination use within patient subgroups.