ABSTRACT
Background: Early during the COVID-19 pandemic patient and provider anxiety concerning in-person visits and travel restrictions may have delayed cancer diagnosis and altered treatment. We evaluated changes in clinical presentation and treatment patterns in multiple myeloma (MM) during the early COVID-19 period compared to historical pre-COVID periods. Methods: Using the nationwide Flatiron Health EHR-derived de-identified database, we compared clinical presentation and treatment patterns in the immediate post-COVID period (2020) to a comparable pre-COVID period (2018 and 2019). We focused on two separate clinical settings: 1) patients newly diagnosed with MM during February-June in the years of interest (NEWPT) with evidence of management within 90 days and follow-up for 7 months;and 2) patients diagnosed with MM during 2014-2019 receiving active treatment as of February (2018, 2019, 2020, ACTIVE) and follow-up for 11 months. Delayed clinical presentation was assessed using baseline (90 days before diagnosis/index date) measures of ISS stage, ECOG performance status, anemia, and kidney function. We examined treatment patterns (choice of regimen) of both cohorts in the two time periods. We compared clinical features of initial presentation in pre-COVID and COVID period using Pearson's χ 2 test. For NEWPT, we also utilized Kaplan-Meier curves and log-rank test to compare time to treatment initiation between the two periods. Multivariable Cox proportional hazards regression model with death as a competing risk was used to determine impact of COVID on treatment initiation by adjusting sex, age at diagnosis, race, insurance, stage, baseline ECOG, and hospital setting. All analyses were conducted in SAS (Version 9.4, SAS Institute, Cary, North Carolina) with 2 sided tests and a type I error of 5%. Results: Our study included 1319 NEWPT (964 pre-COVID and 355 COVID) and 2206 ACTIVE (1014 pre-COVID and 1192 COVID) patients. In the NEWPT cohort, we observed no differences between the pre-COVID and COVID periods in terms of baseline characteristics, including clinical features like stage, ECOG performance status, anemia or kidney function (Table A). Patients in the pre-COVID period were more likely to initiate any treatment (91.1% vs 86.2%, p<.01). Median time to treatment initiation was 30 days pre-Covid and 32 days during the Covid period (log-rank test p=0.04, Figure A). After adjusting for patient demographic, clinical features (extent of anemia, hypercalcemia, kidney dysfunction), and hospital variables (US region, practice type academic vs community), the difference between the two periods was not significant (COVID vs pre-COVID hazard ratio=0.88, 95% confidence interval 0.78-1.10, p=0.07). In NEWPT cohort, compared with their pre-COVID counterparts, patients in COVID period were more likely to receive monoclonal antibody (mAb) (14.4% vs 4.8%, p<.01, Figure B) and used IMID-based regimen as their first line of therapy (80.4% vs 74.3%, p<.01). In ACTIVE cohort, more patients in the pre-COVID period were anemic (Hemoglobin <10 g/L, 14.9% vs 9.7%, p<.01) at baseline than those in the COVID period. As in NEWPT cohort, ACTIVE patients in the COVID period used mAb-based regimen more commonly (28.9% vs 16.9%, p<.01) (Figure C). In addition, fewer ACTIVE treatment patients in the COVID period received cyclophosphamide regimens (7.9% vs 15.1% p<.01). Conclusions: During early COVID-19 pandemic we did not observe evidence of delayed diagnosis or more advanced stage, anemia or kidney disease for NEWPT with MM. MM treatment patterns were notable for higher utilization of mAb, IMID-based therapies and decreased use of cyclophosphamide regimens, without significant change in time to treatment initiation. Reassuringly, changes in treatment-patterns during COVID pandemic were modest, some likely reflecting changes in MM treatment landscape (advances in mAb regimens) rather than direct impact of COVID. Further studies are needed to understand how these changes evolve and affect clinical outcomes over time beyond 2020. [Formula presen ed] Disclosures: Neparidze: GlaxoSmithKline: Research Funding;Eidos Therapeutics: Membership on an entity's Board of Directors or advisory committees;Janssen: Research Funding. Zeidan: Jasper: Consultancy;AstraZeneca: Consultancy;Aprea: Consultancy, Research Funding;Gilead: Consultancy, Other: Clinical Trial Committees;Loxo Oncology: Consultancy, Other: Clinical Trial Committees;Astellas: Consultancy;Agios: Consultancy;Kura: Consultancy, Other: Clinical Trial Committees;Jazz: Consultancy;Pfizer: Other: Travel support, Research Funding;Genentech: Consultancy;Geron: Other: Clinical Trial Committees;BMS: Consultancy, Other: Clinical Trial Committees, Research Funding;ADC Therapeutics: Research Funding;Novartis: Consultancy, Other: Clinical Trial Committees, Travel support, Research Funding;Boehringer Ingelheim: Consultancy, Research Funding;Astex: Research Funding;BeyondSpring: Consultancy;Incyte: Consultancy, Research Funding;Daiichi Sankyo: Consultancy;Epizyme: Consultancy;BioCryst: Other: Clinical Trial Committees;Cardiff Oncology: Consultancy, Other: Travel support, Research Funding;Janssen: Consultancy;Ionis: Consultancy;Amgen: Consultancy, Research Funding;Acceleron: Consultancy, Research Funding;AbbVie: Consultancy, Other: Clinical Trial Committees, Research Funding. Podoltsev: Pfizer: Honoraria;PharmaEssentia: Honoraria;Blueprint Medicines: Honoraria;Incyte: Honoraria;Novartis: Honoraria;CTI BioPharma: Honoraria;Bristol-Myers Squib: Honoraria;Celgene: Honoraria. Shallis: Curis: Divested equity in a private or publicly-traded company in the past 24 months. Ma: Celgene/Bristol Myers Squibb: Consultancy, Research Funding. Davidoff: Amgen: Consultancy;AbbVie: Other: Family member consultancy. Huntington: AstraZeneca: Consultancy, Honoraria;TG Therapeutics: Research Funding;Thyme Inc: Consultancy;Flatiron Health Inc.: Consultancy;Genentech: Consultancy;SeaGen: Consultancy;Novartis: Consultancy;Pharmacyclics: Consultancy, Honoraria;Servier: Consultancy;Bayer: Honoraria;DTRM Biopharm: Research Funding;AbbVie: Consultancy;Celgene: Consultancy, Research Funding.
ABSTRACT
Background/objectives: The COVID-19 pandemic led to a dramatic reduction of in-person medical care in the general population;however, impacts have not been well-characterized for patients with hematologic malignancies. This study assessed the impact of COVID-19 on healthcare delivery for patients with hematologic malignancies with documented active treatment. Methods: Patients from the nationwide Flatiron Health electronic health record (EHR)-derived de-identified database with confirmed diagnosis of AML, DLBCL, FL, MCL, CLL or MM, and age ≥ 18 years at initial diagnosis were included. To be included in the study, documented receipt of at least one systemic, non-maintenance line of therapy between March 1, 2016 - February 28, 2021 was required. Patients were categorized into treatment types within lines of therapy: Oral therapy (OralTx);outpatient infusions (OutPtTx);and inpatient infusions, including hematopoietic transplants and CAR-T cell therapy (InPtTx). Monthly visit rates were calculated as the number of visits (telemedicine or in-person [in-clinic treatment administration, vitals, and/or labs]) per active patient per 30-day standardized month. Only visits occurring within a line of therapy were included (i.e. during active therapy, excluding surveillance). Telemedicine was only available for ion during the pandemic period. We used time-series forecasting methods on pre-pandemic monthly visit rate data (March 2016 - February 2020) to estimate projected counterfactual visit rates between March 2020 - February 2021 (expected in-person visit rates if the pandemic had not occurred) for all diseases combined, each disease, and each treatment type. Differences between projected and actual monthly visit rates during the pandemic period were considered statistically significant and related to the pandemic if the actual visit rate was outside of the 95% prediction interval (PI) surrounding the projected estimate. Results: A total of 22,559 patients were included in this analysis (6,241 OralTx, 14,501 OutPtTx, 7,675 InPtTx): 4,069 AML, 3,641 DLBCL, 2,004 FL, 1,899 MCL, 4,574 CLL and 6,701 MM. There was a gradual downward trend in in-person visit rates across all diseases over the study period (March 2016 - February 2021, Figure) and general visit frequencies were lower for OralTx and higher for OutPtTx and InPtTx overall. For all diseases combined, early pandemic months (March - May 2020) saw an 18% (95% PI 8.9% - 25%) reduction in in-person visit rates averaged across OralTx and OutPtTx, with the projected rate being 1.5 (95% PI 1.3 - 1.6) visits per patient per month, compared to an actual rate of 1.2. Reductions in the in-person visit rates were significant for all 3 treatment types for MM, for OralTx for CLL, and for OutPtTx for MCL and CLL. Telemedicine visit rates were greatest for patients who received OralTx, followed by OutPtTx, then InPtTx, with greater use in the early pandemic months and subsequent decrease in later months. All in-person visit rates increased close to predicted rates in the later half of the pandemic period. Conclusions: In treatment of hematologic malignancies, overall documented in-person visit rates for patients on OralTx and OutPtTx significantly decreased during early pandemic months, but returned close to the projected rates later in the pandemic. There were no significant reductions in the overall in-person visit rate for patients on InPtTx. Variability in these trends by disease type was observed, with significant reductions in in-person visits impacting MM, CLL, and MCL. Figure. Visit rates over time according to treatment category [Formula presented] Disclosures: Lau: Roche: Current equity holder in publicly-traded company;Flatiron Health Inc: Current Employment. Wang: Roche: Current equity holder in publicly-traded company;Flatiron Health: Current Employment. Davidoff: AbbVie: Other: Family member consultancy;Amgen: Consultancy. Huntington: Bayer: Honoraria;Thyme Inc: Consultancy;Novartis: Consultancy;Flatiron Health Inc.: Consultancy;Genentech: Consultancy;eaGen: Consultancy;Servier: Consultancy;AstraZeneca: Consultancy, Honoraria;TG Therapeutics: Research Funding;DTRM Biopharm: Research Funding;AbbVie: Consultancy;Pharmacyclics: Consultancy, Honoraria;Celgene: Consultancy, Research Funding. Calip: Pfizer: Research Funding;Roche: Current equity holder in publicly-traded company;Flatiron Health Inc: Current Employment. Shah: AstraZeneca: Research Funding;Seattle Genetics: Research Funding;Epizyme: Research Funding. Stephens: CSL Behring: Consultancy;TG Therapeutics: Membership on an entity's Board of Directors or advisory committees;AstraZeneca: Consultancy;Celgene: Consultancy;JUNO: Research Funding;Mingsight: Research Funding;Abbvie: Consultancy;Arqule: Research Funding;Adaptive: Membership on an entity's Board of Directors or advisory committees;Novartis: Research Funding;Epizyme: Membership on an entity's Board of Directors or advisory committees;Beigene: Membership on an entity's Board of Directors or advisory committees;Innate Pharma: Membership on an entity's Board of Directors or advisory committees;Karyopharm: Membership on an entity's Board of Directors or advisory committees, Research Funding. Miksad: Flatiron Health Inc: Current Employment, Current holder of individual stocks in a privately-held company;Roche: Current equity holder in publicly-traded company. Parikh: GNS Healthcare: Current holder of individual stocks in a privately-held company;Onc.AI: Current holder of individual stocks in a privately-held company;Humana: Honoraria, Research Funding;Nanology: Honoraria;Thyme Care: Honoraria;Flatiron Health Inc: Honoraria. Takvorian: Pfizer: Research Funding;Genentech: Consultancy. Neparidze: GlaxoSmithKline: Research Funding;Janssen: Research Funding;Eidos Therapeutics: Membership on an entity's Board of Directors or advisory committees. Seymour: Flatiron Health Inc: Current Employment;Janssen: Membership on an entity's Board of Directors or advisory committees;Roche: Current equity holder in publicly-traded company;Karyopharm: Honoraria, Membership on an entity's Board of Directors or advisory committees;Pharmacyclics: Membership on an entity's Board of Directors or advisory committees.
ABSTRACT
Background/objectives: The COVID-19 pandemic impacted healthcare visit trends, propelling healthcare systems to reduce in-person visits and hospital admissions and increasingly rely on telemedicine;whether there are differences in these trends across racial groups is unknown. This study investigated potential racial disparities in visits during the pandemic for patients with documented active treatment for hematologic malignancies. Methods: We used the nationwide Flatiron Health electronic health record (EHR)-derived de-identified database to select patients with confirmed diagnosis of AML, DLBCL, FL, MCL, CLL or MM, at least 18 years old at initial diagnosis, and documented race in the EHR as Black/African American or White were included. Patients were categorized into treatment types within lines of therapy: Orals (orals + outpatient infusions with orals) vs. Inpatient treatments (chemotherapy, hematopoietic transplants & CAR-T cell therapy). Monthly visit rates were calculated as the number of visits (telemedicine or in-person [in-clinic treatment administration, vitals, and/or labs]) per active patient per 30-day standardized month, except for months in which the patient was considered not active (e.g. no documented therapy, surveillance). We used time-series forecasting methods on pre-pandemic monthly visit rate data (March 2016 - February 2020) to estimate projected counterfactual monthly visit rates (expected rates if the pandemic did not occur) between March 2020 - February 2021 for all diseases combined, for each disease, each treatment type, and each race. Differences between projected and actual monthly visit rates during the pandemic period were considered significant and related due to the pandemic if the actual visit rate was outside of the 95% prediction interval (PI) surrounding the projected estimate. We used cross-correlation analysis to test for significant differences in visit rates between Black and White patients. Results: The analysis included 17,621 patients (2,225 Black, 15,396 White): 3,041 AML, 2,715 DLBCL, 1,558 FL, 1,511 MCL, 3,813 CLL and 5,244 MM (1,166 Black, 4078 White). Across all diseases and treatment categories, Black patients had no significant reductions in in-person visit rates throughout the pandemic period compared to the projected rates. There was, however, an 18% statistically significant reduction (95% PI 9.9% - 25%) in in-person visit rates for White patients on orals during early pandemic months (March - May 2020) from a projected visit rate of 2.0 (95% PI 1.8 - 2.2) visits per patient per month to an actual visit rate of 1.61. There was no significant reduction in in-person visit rates for White patients on inpatient treatments. Telemedicine uptake was significantly higher for White patients compared with Black patients for all diseases combined across all treatment categories (Figure A & B) (t = 9.5, p < 0.01), AML inpatient treatments (t = 2.4, p = 0.04), MM orals (Figure C) (t = 6.0, p < 0.01) and MM inpatient treatments (Figure D) (t = 2.3, p = 0.04). Conclusions: A tradeoff in reductions in in-person visits and uptake of telemedicine use was observed overall. White patients had significantly higher telemedicine uptake compared with Black patients for both oral and inpatient treatments. In-person visit rates for Black patients were unchanged regardless of treatment category. These in-person visit rates reflect documented telemedicine use disparities, which requires further study into possible compound causes, including economic and societal factors. Figure. Trends over time in telemedicine visit rates for White patients (blue line) and Black patients (black line) [Formula presented] Disclosures: Neparidze: Eidos Therapeutics: Membership on an entity's Board of Directors or advisory committees;GlaxoSmithKline: Research Funding;Janssen: Research Funding. Lau: Flatiron Health Inc: Current Employment;Roche: Current equity holder in publicly-traded company. Wang: Flatiron Health: Current Employment;Roche: Current equity holder in publicly-traded company. Davidoff: Amgen: Consultancy;AbbVie: Other: Family member consultancy. Huntington: Bayer: Honoraria;Servier: Consultancy;Pharmacyclics: Consultancy, Honoraria;Thyme Inc: Consultancy;Genentech: Consultancy;AbbVie: Consultancy;SeaGen: Consultancy;Celgene: Consultancy, Research Funding;Flatiron Health Inc.: Consultancy;DTRM Biopharm: Research Funding;TG Therapeutics: Research Funding;AstraZeneca: Consultancy, Honoraria;Novartis: Consultancy. Calip: Flatiron Health Inc: Current Employment;Roche: Current equity holder in publicly-traded company;Pfizer: Research Funding. Shah: AstraZeneca: Research Funding;Seattle Genetics: Research Funding;Epizyme: Research Funding. Stephens: Adaptive: Membership on an entity's Board of Directors or advisory committees;Celgene: Consultancy;Abbvie: Consultancy;CSL Behring: Consultancy;Novartis: Research Funding;Karyopharm: Membership on an entity's Board of Directors or advisory committees, Research Funding;JUNO: Research Funding;Mingsight: Research Funding;AstraZeneca: Consultancy;Innate Pharma: Membership on an entity's Board of Directors or advisory committees;Beigene: Membership on an entity's Board of Directors or advisory committees;TG Therapeutics: Membership on an entity's Board of Directors or advisory committees;Epizyme: Membership on an entity's Board of Directors or advisory committees;Arqule: Research Funding. Miksad: Flatiron Health Inc: Current Employment, Current holder of individual stocks in a privately-held company;Roche: Current equity holder in publicly-traded company. Parikh: Onc.AI: Current holder of individual stocks in a privately-held company;Humana: Honoraria, Research Funding;Flatiron Health Inc: Honoraria;Thyme Care: Honoraria;Nanology: Honoraria;GNS Healthcare: Current holder of individual stocks in a privately-held company. Takvorian: Genentech: Consultancy;Pfizer: Research Funding. Seymour: Janssen: Membership on an entity's Board of Directors or advisory committees;Roche: Current equity holder in publicly-traded company;Pharmacyclics: Membership on an entity's Board of Directors or advisory committees;Flatiron Health Inc: Current Employment;Karyopharm: Honoraria, Membership on an entity's Board of Directors or advisory committees.