Rapid Uptake of Immunotherapy, but Slower in Small, Rural Practices

Patricia McKnight

January 17, 2023

The location and size of an oncology practice may impact whether or not patients have access to the latest development in cancer treatment, including immunotherapy, a nationwide study suggests. 

The study used fee-for-care Medicare claims to look at the adoption of immunotherapy between January 2021 and September 2022. It looked specifically at the five cancer types for which these therapies were approved by the US Food and Drug Administration during that period (ie, melanoma, kidney cancer, lung cancer, and head and neck).

It found that 75%-95% of oncology practices had adopted immunotherapy with 2 years of FDA approval.

However, adoption of immunotherapy was not equal across practice types.

Compared to urban practices, rural practices adopted immunotherapy at a much slower rate, although they caught up over time. 

The size of the practice also determined how quickly immunotherapy was adopted.  Practices with six or more physicians had higher adoption than small practices, especially in urban areas. 

The findings were published online January 5 in JAMA Oncology

Senior author Nancy L. Keating, MD, MPH, discussed the study in a  JAMA Oncology podcast. She said the research team decided to specifically focus on the delivery patterns of immunotherapy because it was "pretty marked advance" and very effective in many cancer types.

"Another nice thing about immunotherapy is that theoretically, it should be one of those things that could be adopted anywhere because it doesn't require specialized equipment [and] it's generally well tolerated by patients," Keating said.

There was also widespread publicity given to immunotherapy, both in the medical literature and at medical meetings, as well as in the lay media, which probably influenced the take-up of these new drugs.

Overall, the results show that immunotherapy was taken up "pretty rapidly and pretty completely," Keating commented in the podcast. She noted that the study looked only at Medicare claims, which would account for about 30%-40% patients in an oncology practice, and she speculated that if the study had also included commercial patients, the adoption of immunotherapy would be shown to be even faster and more complete.   

In the study, the authors contrast this uptake of immunotherapy with data that has been previously reported for bevacizumab (Avastin), an innovative biological agent that was approved for several different cancer types. However, bevacizumab was adopted by only 20%-50% of oncology practices (and they tended to be academic centers), and so it wasn't the "home run" that was seen with immunotherapy (adopted by 75%-95% of practices), Keating commented.

The adoption of immunotherapy may be a "best-case" scenario, she commented, because these drugs had so many indications and their benefits were "so widely recognized." She doubts that there would be a similar scenario for new drugs that target a much smaller patient population, or a more unusual cancer type.

Study Details   

The authors used data from Medicare fee-for-service beneficiaries undergoing 6-month chemotherapy episodes. The data set included 71,659 episodes at 1732 oncology practices, which were evaluated for location (rural vs urban), affiliation type (academic system, nonacademic system, independent), and size (1 to 5 physicians vs 6 or more physicians).

Of the identified practices, 264 (15%) were rural, 900 (52%) were independent, and 492 (28%) had 1 to 5 physicians. 

Adoption of immunotherapy in rural practices was 11 percentage points lower than in urban practices in the years after FDA approval. Differences were largest immediately after FDA approval, with rural practices catching up to urban counterparts over time (eg, 13% gain 2 years after approval). 

Smaller practices were also 27 percentage points less likely to adopt immunotherapy after FDA approval, with smaller differences later in the study period.

When comparing independent practices to nonacademic systems, researchers found they had similar adoption patterns, but both had lower adoption rates compared with academic systems (vs independent, −6 percentage points; vs nonacademic systems, −9 percentage points).

"Findings of the present study suggest a possible mechanism: small or rural practices fall behind in terms of adopting new technologies," the team concludes. "This finding is consistent with other research reporting lower adoption of high-cost technologies at rural or small hospitals." 

The study was supported by grants from the Agency for Healthcare Research and Quality and the National Cancer Institute. Keating r eported receiving grants from the Agency for Healthcare Research and Quality and the National Cancer Institute during the conduct of the study; grants from Arnold Ventures and Commonwealth Fund outside the submitted work; and other funding from the Centers for Medicare & Medicaid Services outside the submitted work. Disclosures for the other authors can be found with the original article.

JAMA Oncol. Published online January 5, 2023. Abstract

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