Uninsured patients and patients with Medicaid who have germ cell tumors or glioblastoma multiforme experienced poorer outcomes than their privately insured counterparts, according to results of two studies published in Cancer.
Although the relationship between insurance status and outcomes has been studied in numerous diseases, little data existed on the influence of insurance coverage — or lack thereof — on the diagnosis, treatment and likelihood of survival among patients with these two distinct cancer types.
Christopher J. Sweeney
Christopher J. Sweeney, MBBS, associate professor of medicine at Harvard Medical School and senior physician at Dana-Farber Cancer Institute, and colleagues observed the impact of insurance status on disease presentation, treatment options and survival outcomes of patients with germ cell tumors.
Judy Huang, MD, director of the department of neurosurgery at Johns Hopkins Bayview Medical Center and professor of neurosurgery at Johns Hopkins Medicine, and colleagues similarly studied outcomes related to insurance coverage on adult patients receiving treatment for glioblastoma multiforme.
In both studies, insured patients had the best outcomes, whereas those with Medicaid or without insurance were more likely to die of their disease.
“This suggests that while improvements in medical therapy have resulted in longer survival, this benefit is less likely to be accessible to Medicaid-insured or uninsured patients,” Huang said in a press release.
Younger patients, greater risks
Approximately 95% of testicular cancers originate in the germ cells, which are located in the testicles and produce sperm.
Testicular cancer occurs primarily in younger patients, with 73% of cases diagnosed in individuals aged 20 years to 44 years. The median age of diagnosis is 33 years.
However, 23.5% of individuals aged 26 years to 34 years are uninsured, representing the most un- and underinsured population.
Prior research suggested that uninsured patients with testicular cancer were more likely to present at later stages and with more advanced tumors. Further, uninsured patients appeared less likely to receive definitive treatment and more likely to die of the disease.
Sweeney and colleagues sought to comprehensively study the associations between insurance status and disease stage at presentation, treatment receipt and OS among men diagnosed with germ cell tumors.
The researchers identified 10,211 men in the SEER database who received treatment for germ cell and trophoblastic gonadal neoplasms from 2007 to 2011. Of this cohort, 77% (n = 7,818) had private insurance and 13% (n = 1,330) had insurance through Medicaid.
The remaining 10% (n = 1,063) were uninsured.
Factors associated with a lack of insurance included younger age (29 years or younger, 52%), lower household income (< $53,590, 37%) and residence in the South (30%).
A greater risk for metastatic disease at diagnosis occurred among uninsured men (RR = 1.26; 95% CI, 1.15-1.38) and men insured through Medicaid (RR = 1.62; 95% CI, 1.51-1.74) than men with private insurance.
These men also had an increased likelihood of presenting with a larger tumor ( 4 cm; uninsured, RR = 1.32; Medicaid, RR = 1.36), and of having intermediate- or poor-risk disease at diagnosis (uninsured, RR = 1.22; Medicaid, RR= 1.39).
Most men in all insurance groups underwent a radical orchiectomy (uninsured, 97%; Medicaid, 95%; private insurance, 98%). Despite this, uninsured men diagnosed with stage I germ cell seminoma were less likely to receive additional radiation after orchiectomy (RR = 0.82; 95% CI, 0.7-0.95) and a lymph node dissection (RR = 0.74; 95% CI, 0.57-0.94).
Insurance status also influenced all-cause and disease-specific survival outcomes. Multivariate analyses showed higher rates of disease-specific mortality among men with Medicaid (HR = 1.51; 95% CI, 1.08-2.1) and uninsured men (HR = 1.88; 95% CI, 1.29-2.75). These patients also had higher rates of all-cause mortality (Medicaid, HR = 1.69; uninsured, HR = 1.58).
The researchers acknowledged potential study limitations, including the lack of chemotherapy data captured in the SEER database and the lack of data on individual-level insurance plans.
Additionally, they acknowledged that income and education data may have been misclassified in the database.
“Although testis cancer is curable with chemotherapy, this study supports the notion that lack of insurance may lead to delays in diagnosis and more advanced, less curable disease,” Sweeney said in a press release. “Our findings support the belief that early diagnosis and management is key, and removal of barriers to access to health care should be implemented.”
Glioblastoma treatment, survival disparities
Glioblastoma multiforme is the most common primary brain tumor in adults, and remains associated with poor outcomes. Fewer than 5% of patients survive 5 years, with a median survival of 14.6 months from diagnosis.
Huang and colleagues used the SEER database to identify 13,665 adults (mean age, 62.6 ± 13.6 years; 42.2% women) diagnosed between January 2007 and December 2012. All patients included in the study had insurance data included in their records.
The majority of the cohort (84.8%; n = 11,591) had private insurance, whereas 11.1% (n = 1,516) had Medicaid and 4.1% (n = 558) lacked insurance.
Factors associated with having private insurance included older age, female sex, non-Hispanic white race, marriage and small tumor size at diagnosis.
Seventy-six percent of patients underwent surgical resection, of whom 78.5% received radiation therapy before or after surgery; 59.7% of the entire cohort received both surgery and radiation.
Patients with Medicaid were less likely to undergo surgery (OR = 0.74; 95% CI, 0.65-0.85), and adjuvant radiation was less common among patients with Medicaid (OR = 0.62; 95% CI, 0.55-0.7) and uninsured patients (OR = 0.57; 95% CI, 0.48-0.69).
Median OS in the overall population was 10.1 months (95% CI, 9.1-10.1). Survival rates declined from 45% at 1 year to 6.3% at 5 years.
Factors independently associated with shorter survival included older age (HR = 1.04; 95% CI, 1.03-1.04), male sex (HR = 1.08; 95% CI, 1.03-1.12), large tumor size (HR = 1.26; 95% CI, 1.21-1.32), having Medicaid (HR = 1.1; 95% CI, 1.03-1.17) and lack of insurance (HR = 1.14; 95% CI, 1.02-1.27).
Researchers observed a reduced risk for mortality among patients who received radiation (HR = 0.4; 95% CI, 0.38-0.42) or were married (HR = 0.86; 95% CI, 0.82-0.9).
There was no significant survival difference between black patients and non-Hispanic white patients. However, other racial populations included in the study had longer survival outcomes than non-Hispanic white patients (HR = 0.77; 95% CI, 0.7-0.85).
The researchers further observed an overall progressive improvement in survival among privately insured patients during the study period (P = .015); however, this trend did not extend to uninsured patients or patients covered by Medicaid.
The researchers acknowledged study limitations. They included patients with clinically and pathologically diagnosed glioblastoma to avoid the potential for attrition bias implicit in excluding clinically diagnosed patients.
Additionally, the researchers did not have access to income or educational data and were unable to control for insurance variances between states.
“This study indicates significant disparities in the management of patients with glioblastoma multiforme under our existing health care insurance framework that need to be addressed,” Wuyang Yang, MD, MS, neurosurgery research fellow at Johns Hopkins Medicine, said in a press release.
Improving health care access
Health care disparities continue to persist in the United States, despite advances in treatment and legislature, such as the Patient Protection and Affordable Care Act, Michael T. Halpern, MD, PhD, MPH, associate professor of health administration and policy at Temple University School of Public Health, and Otis W. Brawley, MD, FACP, chief medical officer of the American Cancer Society and a HemOnc Today Editorial Board member, wrote in a related editorial.
Otis W. Brawley
“Patient sociodemographic and cultural characteristics are often associated with barriers to the receipt of high-quality and timely cancer care,” Halpern and Brawley wrote. “These barriers, in turn, may significantly affect an individual patient’s long-term functional status, quality of life and survival. ... Many studies have reported on barriers to optimal cancer care associated with health insurance status.”
Future research should focus on disparities based on type of insurance, in addition to lack of insurance, according to Halpern and Brawley.
“Important aspects of the quality of cancer care include timeliness; care consistent with accepted clinical screening, diagnostic, and treatment guidelines; and access to survivorship care services,” they wrote. “In some studies, patients receiving routine care through health maintenance organizations tend to have more coordinated, higher quality care in comparison with those with fee-for-service insurance. However, other studies have reported an increased likelihood of adjuvant therapy and improved outcomes among individuals diagnosed with cancer in fee-for-service Medicaid vs. managed care plans. More research is needed on how the specifics of insurance coverage and insurance-related policies affect the quality of care and outcomes.”
Both studies highlight a need to expand access to health care, Halpern and Brawley concluded.
“These two studies join a long litany of studies demonstrating that a substantial number of Americans diagnosed with cancer die prematurely,” Halpern and Brawley wrote. “The underserved deserve service. Adequate health care should be considered an inalienable human right, and greater emphasis is needed on realizing strategies that will make this happen throughout the continuum of cancer care.” – by Cameron Kelsall
Halpern MT and Brawley OW. Cancer. 2016;doi:10.1002/cncr.30158.
Markt SC, et al. Cancer. 2016;doi:10.1002/cncr.30159.
Rong X, et al. Cancer. 2016;doi:10.1002/cncr.30160.
Disclosure: Sweeney and colleagues report no relevant financial disclosures. Huang reports no relevant financial disclosures; however, one researcher from that study reports research funding from, as well as consultant and speakers bureau roles with, Agenus, Bristol-Myers Squibb, Celldex Therapeutics, Immunocellular Therapeutics and Stryker Corporation, all outside the submitted work. Halpern reports a consultant role with AbbVie outside the submitted work. Brawley reports no relevant financial disclosures.