Rural, Small Practices Slower to Adopt Immunotherapies

Rural and small cancer practices are slower to adopt immunotherapy, or immune checkpoint inhibitors, following FDA approval, according to a new cohort study. Findings, published in JAMA Oncology are based on Medicare claims from more than 1700 oncology practices.

However, the study also found most oncology practices adopted immunotherapy within 2 years of FDA approval for all cancer types studied. Similar adoption was seen across independent practices and those affiliated with nonacademic systems, but both practice types had less adoption than academically affiliated ones.

Immunotherapies mark an important breakthrough in cancer treatment and can substantially improve outcomes for patients, but little is known about which practices adopt the therapy or the pace at which they do so, the study authors said.

“Understanding variation in technology adoption is important in the context of cancer care because cancer is the second leading cause of death in the United States and a substantial contributor to morbidity,” they wrote. And although innovations in treatment have lowered the mortality risk from cancer, they have also made treatment more complex in general.

To carry out the current study, the researchers used data from Medicare fee-for-service beneficiaries who underwent chemotherapy between 2010 and 2017. The claims data represented a random 20% sample of beneficiaries, and 71,659 claims were included in the analyses.

The researchers assessed the data on immunotherapies for 4 types of cancer: melanoma, kidney cancer, lung cancer, and head and neck cancer. The treatment was approved for melanoma in 2011, for kidney and lung cancer in 2015, and for head and neck cancer in 2016.

Of the 1732 practices included in the investigation, 15% were rural, 52% were independent, and 28% were considered small, or had between 1 and 5 physicians. Any practice with 6 or more physicians was considered large.

Following FDA approval, immunotherapy adoption was 11 percentage points lower at rural practices than urban practices (95% CI, −16% to −6%). Adoption was also 27 percentage points lower at smaller practices than larger ones (95% CI, −32% to −22%).

Investigators used 2010 Rural-Urban Commuting Area codes for each practice’s ZIP code to determine if they were urban or rural. Rural practices tended to have more non-Hispanic White patients compared with urban practices. These practices also had higher shares of patients living in ZIP codes with median household incomes below $40,000.

The finding that small and rural practices fall behind others when adopting new technologies is consistent with other research, the authors noted. However, because immunotherapy use requires little specialized training and equipment, barriers to adoption are likely low.

“The shape of the adoption curves was similar for smaller and rural practices compared with larger and urban practices, but the start of adoption was later; this pattern suggests that interventions focusing on initial use may be particularly important to address differences in adoption,” the researchers said.

Differences between patients at each practice could result in different adoption rates, marking a limitation to the observational study. The investigators were also unable to account for any use of immunotherapies prior to FDA approval.

“A natural question is whether immunotherapy adoption has changed the productivity of oncology care,” the researchers concluded. “Future work could usefully measure the benefits and costs of adoption across practice types, which was not observable in the data used in this study.”

Reference

Carroll CE, Landrum MB, Wright AA, Keating NL. Adoption of innovative therapies across oncology practices—evidence from immunotherapy. JAMA Oncol. Published online January 5, 2023. doi:10.1001/jamaoncol.2022.6296