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Medscape
21-07-2025
- Health
- Medscape
Insurance-Survival Gap Growing in Immunotherapy Era
TOPLINE: 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.
Medscape
08-07-2025
- Health
- Medscape
Real-World Data: Adjuvant Therapy for BRAF-Mutated Melanoma
This transcript has been edited for clarity. Hello, everybody. My name is Teresa Amaral. Welcome back to this Medscape Oncology series on melanoma. Today, we'll finalize a discussion about real-world data on adjuvant therapy in patients with BRAF -mutated melanoma. We discussed the visual comparison between immunotherapy and targeted therapy using real-world data. We also discussed the benefit in terms of relapse-free survival and distant metastasis-free survival in this adjuvant setting when we compared the two therapies, showing that visual comparison seems to show a better benefit for patients receiving targeted therapy compared to immunotherapy. We looked into the differences in terms of quality of life and the toxicity profile for both therapies. Now, we will look into the last aspect that we need to discuss with our patients, which is what we do when the patients have a relapse. Obviously, it is different whether the patients have a relapse under adjuvant therapy or off adjuvant therapy. Patients who have a recurrence under adjuvant targeted therapy seem to benefit from programmed cell death protein 1 (PD-1) therapy afterward in a similar way as patients who had PD-1 monotherapy in stage IV and were treatment naive. Patients with recurrence under adjuvant PD-1 therapy do not seem to benefit from continuing PD-1 therapy, but they might benefit from other immunotherapies, such as ipilimumab or the combination of ipilimumab plus PD-1. We have other real-world data, which we've discussed in the episodes before, on where to go in terms of immunotherapy judgment setting. Even if we have a prolongation in terms of relapse-free survival or metastasis-free survival, when we look into overall survival data from real-world studies, we don't see a benefit in either of the two cohorts, one before introducing adjuvant therapy and another after introducing adjuvant therapy. This is also something that we need to discuss with our patients when we propose adjuvant therapy. The paper I mentioned before is an indirect comparison, and of course, it needs to be read as so. There are real-world data that have been analyzed, but obviously, we cannot change the data and how they were analyzed. When we look into the relapse-free survival events, we need to consider that these events are dependent on the timing when the imaging evaluation was performed. If you have an imaging evaluation that was performed a little bit earlier, you might detect relapse-free survival earlier as compared to an imaging evaluation that was performed later. The criteria for including these studies in this analysis was the same, but inclusion criteria may vary in the different trials, which might lead to a bias. Another aspect that is important to retain from this analysis is that we included both patients with BRAF wild-type and BRAF -mutated melanoma, because we could not separate these as we didn't have access to raw data. We also included all patients despite the BRAF mutation subtype. We didn't know if the patients were BRAF V600E or K, although the majority were reported as having BRAF V600E. We also were not able to analyze the data based on the substage — so stage IIIA to IIID. We included all the patients as stage III, but not the substage. Although the median follow-up time is long, it might not be long enough to capture all the events in the adjuvant setting. We probably need an update of this work in the near future. We were unable to exclude a couple of patients that were stage IV with no evidence of disease that were included in the different publications because we didn't have access to the raw data. We didn't perform any statistical comparison because of the differences in terms of the publications that we selected. The comparison was visually performed based on the formula that I mentioned in the first episode of this series. We have some advantages from this analysis. One is the number of patients, where more than 3600 patients were included. We included analyses that started around 2018, which means that, for the majority of the patients, they would have had access to PD-1 therapies or PD-1-based therapies as in the modern era if they had progressive disease or a recurrence. We don't know if this is the case for all the patients included in the analysis. Finally, grouping all the analyses and doing this digitalization using this visual comparison is obviously, I would say, an advantage. Another advantage is the fact that we used weighted average calculations to produce these Kaplan-Meier curves, showing that there is a concordance among the different works that we selected for this analysis. In conclusion, I would say that, based on this real-world analysis, targeted therapy seems to have a better outcome when we look into relapse-free survival and distant metastasis-free survival in stage III. Targeted therapy has a different profile from immunotherapy, and this needs to be discussed with the patients, especially when we look into long-term toxicity. Also, the impact in terms of quality of life between these two therapies seems to be different, and this needs to be taken into consideration when we discuss this with our patients. With that, I'll finish this three-episode series. I look forward to your comments and to our next series together. Enjoy your day.
