EPH139
Deprivation and access to care among patients with melanoma in the UK
FIGURE 1. Participant Characteristics
N (1072 Overall)
Deprivation Index Population Quintiles (N=892) Most Deprived Quintile
82
2nd Quintile
130
Median
186
4th Quintile
216
Least Deprived Quintile
278
Postcode Not Reported
180
Melanoma Stage (N=137) I
17
II
14
III
43
IV
40
Uveal Localized
4
Uveal Metastatic
1
Don’t Know
18
BRAF Mutation Status (N=172) Positive
Casey Quinn,1 Mark Larkin,1 Ira Jacobs,2 Suki Kandola,3 and Karen E. Smoyer4 Vitaccess Ltd, Oxford, UK; Pfizer, New York, NY, USA; 3 Envision Pharma Group, London, UK; 4Envision Pharma Group, Philadelphia, PA, USA 1
2
36
Negative
77
Don’t Know/Not Tested
59
Prior Surgery (N=362) For Distant Spread Melanoma
26
For Lymph Node Removal
102
For Primary Melanoma
218
No
16
ECOG Status (N=96) 0
26
1
7
2
2
3
1
4
1
Don’t Know
59
Drug Therapies (N=241) Encorafenib + Binimetinib
2
Spartalizumab + Dabrafenib + Trametinib
1
Trametinib
1
BACKGROUND AND OBJECTIVES
Dabrafenib
7
Ipilimumab
6
Nivolumab
16
Dabrafenib + Trametinib
• Malignant melanoma is the fifth most common cancer in the United Kingdom and a leading cancer in average years of life lost.1
Nivolumab + Ipilimumab
• The aim of this research was to describe the patient journey using digital real-world data, and to investigate melanoma care disparities based on deprivation index data from residential postcodes.3
29
Pembrolizumab
25
Vemurafenib
• Surgical resection is the main treatment for early-stage melanoma. Other therapeutic options for more advanced melanoma include chemotherapy, immunotherapy, targeted cancer drugs, and laser treatment.2 • It is not known, however, whether access to and utilization of melanoma treatment vary equitably.
23
1
None or Other
130
FIGURE 2. Comparison of deprivation among respondents reporting use of any drug therapy or no drug therapy (Chi-squared P-value = 0.000)
Any Drug Therapy (n=102)
No Drug Therapy (n=73)
DATA
0%
20%
Most Deprived Quintile
• The Melanoma UK Study is an observational, noninterventional digital registry of realworld data from people living with melanoma and its treatment in the United Kingdom.4 • The Melanoma UK Study was active from 2016 to 2021 with 1072 consenting participants and 2.6 years of average follow-up.
10%
30%
40%
2nd Quintile
50%
Median
60%
70%
80%
90%
100%
Least Deprived Quintile
4th Quintile
Figure 3. Comparison of deprivation among respondents reporting immunotherapy utilization (Chi-squared P-value = 0.047)
Any Immunotherapy (n=71)
METHODS
Non-Immunotherapy (n=31)
• Components of the disease pathway were mapped using cross-sectional baseline data provided by study participants including diagnosis, staging, and interventions received. • Deprivation index scores were assigned based on official English indices for residential postcodes reported by the study respondents and categorized based on quintiles.3 • Chi-squared tests were conducted, under a null hypothesis of no relationship, between deprivation quintiles and the following participant-reported data:
0%
10%
20%
Most Deprived Quintile
30%
40%
2nd Quintile
50%
Median
60%
4th Quintile
70%
80%
90%
100%
Least Deprived Quintile
Figure 4. Comparison of deprivation among respondents reporting drug therapies by regimen
— Whether respondents reported taking drug monotherapy or combination therapy — The specific drug therapies that respondents reported
Pembrolizumab (n=24)
— Eastern Cooperative Oncology Group (ECOG) Performance Status Scale
Nivolumab + Ipilimumab (n=27)
— Melanoma stage at diagnosis
Dabrafenib + Trametinib (n=20)
— Receipt of BRAF testing
Nivolumab (n=15)
— Previous surgery
Ipilimumab (n=5) Dabrafenib (n=7) Trametinib (n=1)
RESULTS
Spartalizumab + Dabrafenib + Trametinib (n=1) Encorafenib + Binimetinib (n=2)
• There were 892 of the 1072 participants with postcode information and linked deprivation data; sample sizes for clinical data were smaller, ranging from 96 to 362 participants.
0%
10%
20%
30%
Most Deprived Quintile
40%
2nd Quintile
50%
60%
Median
4th Quintile
70%
80%
90%
100%
Least Deprived Quintile
• Summary results for participants (all 1072) at baseline are provided in Figure 1. • Participants resided in areas less deprived on average than the general population: 24% of the study were in the two most-deprived quintiles and 55% of the study were in the two least-deprived quintiles, rather than 40% for each as would be expected. • There were no clear social gradients across melanoma stage at diagnosis, BRAF testing, prior surgery, or ECOG performance status. • Drug therapies present a mixed picture. Overall, 60% of all drug therapy utilization was in participants residing in the two least deprived areas, vs 55% which would have been expected based on the population distribution. • There is a statistically significant difference (P-value = 0.000) between deprivation and any drug vs no drug therapy (Figure 2), but not a statistically significant difference (P-value = 0.874) in mono- vs combination therapy regimens (not shown). • There is a statistically significant difference (P-value = 0.047) between the distributions of deprivation and whether the drug therapy was exclusively immunotherapy (nivolumab, ipilimumab, nivolumab + ipilimumab, pembrolizumab) or not. • We found that 65% of any immunotherapy use was in the least two deprived quintiles compared with 18% in the two most deprived, whereas the equivalent rates for no immunotherapy use were 49% in the least two deprived quintiles and 29% in the two most deprived (Figure 3). • A range of utilization rates by regimen was observed, with no apparent social gradient (Figure 4).
REFERENCES
LIMITATIONS • Multiple challenges exist in using digital real-world data to map the patient journey, in particular, low completion rates and population representativeness. • Completion rates were heterogeneous not only across participants but also across questions and surveys. In this case, low rates of completion meant some unreliable tests. • More participants resided in low deprivation than high deprivation areas, which may have resulted in selection bias. • Despite the limitations, however, these data appear to show inequalities in use of immunotherapies vs other therapy, even while reported use by regimen shows no social gradient.
CONCLUSION • The differences that we found in the utilization of immunotherapies across deprivation categories suggest that disparities do exist that should be addressed. • Reducing health disparities in the United Kingdom will require more detailed individual data and analysis.
1. Melanoma skin cancer statistics. Cancer Research UK. Published May 14, 2015. Accessed September 8, 2022. https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/melanoma-skin-cancer 2. Domingues B, Lopes JM, Soares P, Pópulo H. Melanoma treatment in review. Immunotargets Ther. 2018;7:35-49. doi:10.2147/ITT.S134842 3. Noble S. The English Indices of Deprivation 2019: research report. p.87. Published September 2019. Accessed September 8, 2022. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/833947/IoD2019_Research_Report.pdf 4. Larkin M. The Impact of Melanoma and Drug Treatment in the Real World. clinicaltrials.gov; 2021. Accessed September 7, 2022. https://clinicaltrials.gov/ct2/show/NCT03379454
Presented at ISPOR Europe 2022, 6-9 November 2022; Vienna, Austria and Virtual.