Insurance-Survival Gap Growing in Immunotherapy Era
The approval of immune checkpoint inhibitors (ICIs) was associated with a significant improvement in 2-year overall survival among patients with advanced-stage melanoma, non-small cell lung cancer (NSCLC), or renal cell carcinoma across all insurance types (except uninsured patients with renal cancer); however, the survival disparity between people with private insurance and those without health insurance grew.
METHODOLOGY:
ICIs, such as ipilimumab, nivolumab, and atezolizumab, have markedly improved survival across various cancer types; however, their high costs may limit access for patients who do not have health insurance coverage.
Researchers analyzed data on 183,440 individuals (mean age, 55.5 years; 56.5% men) from the National Cancer Database who were diagnosed with stage IV melanoma (n = 12,048) between 2002 and 2019 as well as those with stage IV NSCLC (n = 152,610) or stage IV renal cell carcinoma (n = 18,782) between 2010 and 2019. The FDA approved ICI treatment for melanoma in 2011 and for NSCLC and renal cell carcinoma in 2015.
At diagnosis, 65.0% of participants had private insurance, 24.1% were enrolled in Medicaid, and 10.9% were uninsured.
The primary outcome was 2-year overall survival. The researchers applied a propensity score-weighted difference-in-differences approach to examine changes in 2-year overall survival before and after the relevant ICI approval among individuals with Medicaid or without health insurance vs those with private coverage.
TAKEAWAY:
Among patients with stage IV melanoma, 2-year overall survival rates increased in the ICI era across all insurance types but not to the same degree: uninsured from 16.2% to 28.3%, Medicaid from 14.1% to 29.6%, and private insurance from 28.7% to 46.0%. The survival gap between the privately insured and uninsured widened significantly by 6.1 percentage points after adjusting for comorbidities and sociodemographic characteristics.
Similarly, overall survival improved among patients with stage IV NSCLC, but the disparity between uninsured and privately insured patients increased by 1.3 percentage points, after adjustment. For renal cell carcinoma, the disparity between uninsured and privately insured patients increased by 5.8 percentage points but was not significant.
After excluding data for the first post-approval year to account for lags in uptake, survival disparities between uninsured and privately insured patients widened significantly for all three cancer types: stage IV melanoma (5.0 percentage points), NSCLC (2.2 percentage points), and renal cell carcinoma (6.0 percentage points).
Survival differences between Medicaid-insured and privately insured patients did not change significantly across all cancer types post-ICI approval.
IN PRACTICE:
In this cross-sectional study, the introduction of ICIs was associated with improved survival across insurance types, but preexisting disparities between privately insured and uninsured individuals worsened. 'Programs that reduce barriers to care, such as expanding access to health insurance coverage, providing comprehensive financial assistance to people without health insurance coverage, and making new treatments more affordable, may help to mitigate these disparities,' the authors concluded.
SOURCE:
This study, led by Jingxuan Zhao, PhD, MPH, of the American Cancer Society, Atlanta, was published online in JAMA Network Open.
LIMITATIONS:
Health insurance was only measured at cancer diagnosis, with no information on subsequent coverage changes. Additionally, the study was limited to examining all-cause mortality due to the lack of data on cancer-specific mortality in the database. The database lacked information on specific treatment agents and the percentage of patients who actually received ICIs is unknown, limiting the analysis to population-level rather than direct treatment effects.
DISCLOSURES:
The authors did not disclose any funding information. Some authors reported receiving grants or honoraria from various sources, outside the current work. Additional disclosures are noted in the original article.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
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