Social determinants of health and other predictors in initiation of treatment with CDK4/6 inhibitors for HR+/HER2-metastatic breast cancer

Abstract

Simple Summary A new class of therapy named cyclin-dependent kinase 4/6 inhibitors (CDK4/6is) is the recommended preferred treatment for patients with metastatic breast cancer (MBC) who have the HR+/HER2- subtype; however, several barriers may still exist that prevent or delay the initiation of this treatment. In this observational study, we examined how the social determinants of health (SDOH) (e.g., income status, insurance coverage) and other patient characteristics are associated with the initiation of CDK4/6i for HR+/HER2- MBC in a Medicare population of patients aged 65 years or older. Our analysis showed that Medicare patients residing in areas with high vs. low median household income and those living in areas with a high vs. low proportion of Medicare-only coverage had higher rates of initiating treatment with CDK4/6i. Our study findings highlight the influence of SDOH on access to novel and effective cancer therapies and a need for strategies to improve equity in cancer care.Abstract In hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) metastatic breast cancer (MBC), cyclin-dependent kinase 4/6 inhibitors (CDK4/6is) have replaced endocrine therapy alone as the standard of care; however, several barriers to treatment initiation still exist. We assessed social determinants of health (SDOH) and other factors associated with the initiation of CDK4/6i for HR+/HER2- MBC in the Medicare population. Using a retrospective cohort design, patients aged >= 65 years and diagnosed during 2015-2017 were selected from the SEER-Medicare database. Time from MBC diagnosis to first CDK4/6i initiation was the study outcome. The effect of SDOH measures and other predictors on the outcome was assessed using the multivariable Fine and Gray hazard modeling. Of 752 eligible women, 352 (46.8%) initiated CDK4/6i after MBC diagnosis (median time to initiation: 27.9 months). In adjusted analysis, SDOH factors significantly associated with CDK4/6i initiation included high versus low median household income (HHI) (hazard ratio [HR] = 1.70; 95% CI = 1.03-2.81) and the percentage of population with high versus low Medicare-only coverage (HR = 1.54; 95% CI = 1.04-2.27). In summary, older Medicare patients with HR+/HER2- MBC residing in areas with high median HHI and a high proportion of Medicare-only coverage had higher rates of initiating CDK4/6i, suggesting inequitable access to these novel, effective treatments and a need for policy intervention.