Faraj Kassem S, Kaufman Samuel R, Oerline Mary, Dall Christopher, Srivastava Arnav, Caram Megan E V, Shahinian Vahakn B, Hollenbeck Brent K
Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA.
Department of Urology, Massachusetts General Hospital, Boston, Massachusetts, USA.
Cancer Med. 2025 Jan;14(1):e70552. doi: 10.1002/cam4.70552.
Oral targeted therapies are a standard of care for men with advanced prostate cancer. However, these therapies are expensive, which may be a barrier to some, particularly the most economically disadvantaged. Through investment in programs to assist this population, savings generated from the 340B program have the potential to mitigate barriers to initiating treatment with targeted therapies in these men.
We performed a retrospective study using a 20% national sample of fee-for-service Medicare beneficiaries diagnosed with advanced prostate cancer between 2012 and 2019. The outcome was the patient-level use of a targeted therapy for the first time. This study had two exposures. The first was 340B penetration, representing the percentage of all outpatient hospital revenue in a hospital referral region generated by a 340B hospital. The second was the degree of socioeconomic disadvantage, as measured by the social vulnerability index (SVI). Two separate Cox models were fit to measure relationships between each exposure and use of a targeted therapy. A third model was fitted to assess whether differences in utilization by SVI were mitigated by increasing 340B penetration.
The use of a targeted therapy did not vary with 340B penetration (adjusted HR 1.1, 95% CI 0.96-1.2) for high versus low penetration. Conversely, socioeconomically disadvantaged men were less likely to initiate treatment. Those residing in the third SVI tertile (i.e., most vulnerable) were less likely to start on a targeted therapy compared to men in the first tertile (adjusted HR 0.85, 95% CI 0.78-0.92). However, increasing 340B penetration did not attenuate these differences (Wald test for the interaction term p = 0.10).
There was no association between a region's 340B penetration and use of a targeted therapy. Furthermore, although the use of a targeted therapy decreased with increased SVI, the 340B penetration of a region did not reduce this gap.
口服靶向治疗是晚期前列腺癌男性患者的标准治疗方法。然而，这些治疗费用昂贵，这可能对一些人，尤其是经济上最弱势的人群构成障碍。通过对协助这一人群的项目进行投资，340B计划产生的节省资金有可能减轻这些男性患者开始接受靶向治疗的障碍。
我们使用2012年至2019年间被诊断患有晚期前列腺癌的按服务收费的医疗保险受益人的20%全国样本进行了一项回顾性研究。结果是患者首次使用靶向治疗。这项研究有两个暴露因素。第一个是340B渗透率，代表340B医院在医院转诊区域产生的所有门诊医院收入的百分比。第二个是社会经济劣势程度，通过社会脆弱性指数（SVI）来衡量。拟合两个单独的Cox模型来测量每个暴露因素与靶向治疗使用之间的关系。拟合第三个模型以评估增加340B渗透率是否减轻了SVI在利用率方面的差异。
高渗透率与低渗透率地区相比，靶向治疗的使用与340B渗透率无关（调整后风险比1.1，95%置信区间0.96 - 1.2）。相反，社会经济弱势男性开始治疗的可能性较小。与处于第一三分位数的男性相比，处于SVI第三三分位数（即最脆弱）的男性开始接受靶向治疗的可能性较小（调整后风险比0.85，95%置信区间0.78 - 0.92）。然而，增加340B渗透率并没有减弱这些差异（交互项的Wald检验p = 0.10）。
一个地区的340B渗透率与靶向治疗的使用之间没有关联。此外，尽管靶向治疗的使用随着SVI的增加而减少，但一个地区的340B渗透率并没有缩小这一差距。
