A study led by researchers at the American Cancer Society examining the association between the introduction of immune checkpoint inhibitors (ICIs) and changes in survival disparities by health insurance coverage among patients with newly diagnosed stage IV melanoma, non–small cell lung cancer (NSCLC), or renal cell carcinoma has found a statistically significant widening gap in survival outcomes between privately insured and uninsured individuals with these cancers. Federal policies expanding access to health insurance coverage and making new cancer therapies more affordable are needed to mitigate disparities in survival outcomes, according to the study authors. The study is published in JAMA Open Network.
Study Methodology
The researchers obtained data from the National Cancer Database on individuals ages 18 to 64 years with a new diagnosis of stage IV melanoma, NSCLC, and renal cell carcinoma eligible for ICIs that were approved by the FDA before 2016, including ipilimumab and nivolumab. For each of the cancer types, scientists examined the changes in 2-year survival before and after the introduction of ICIs following FDA approval among individuals without health insurance or with Medicaid, compared with those with private insurance.
Among the 183,440 individuals included in this study, the mean age was 55.5 years and 56.5% were male.
Results
KEY POINTS
- After the introduction of ICIs, there was a statistically significant widening of the gap in survival outcomes between privately insured and uninsured individuals with a new diagnosis of stage IV melanoma, non–small cell lung cancer, or renal cell carcinoma.
- Policies expanding access to health insurance and making new treatments more affordable are needed.
The researchers found that among the individuals newly diagnosed with advanced melanoma, 2-year overall survival rates increased post-ICI approval among the uninsured from 16.2% to 28.3%, and individuals with private insurance from 28.7% to 46.0%, resulting in a widening disparity of 6.1 percentage points (95% confidence interval [CI] = 1.7–10.6 percentage points) after adjusting for sociodemographic characteristics.
Similarly, among individuals with a diagnosis of NSCLC, the survival disparity between those without insurance and those with private insurance widened to 1.3 percentage points (95% CI = 0.2–2.3 percentage points). Survival differences between individuals with Medicaid and those with private insurance did not change significantly with the introduction of ICIs (difference-in-differences [DID] for melanoma = –1.9 percentage points [95% CI = –5.6 to 1.8 percentage points]; DID for NSCLC = 0.4 percentage points [95% CI = –0.4 to 1.2 percentage points]; and DID for renal cell carcinoma = –3.8 percentage points [95% CI = –9.4 to 1.9 percentage points]).
“This serial cross-sectional study found that the introduction of ICIs was associated with widening survival disparity between people without health insurance and those with private insurance. Policies expanding access to health insurance coverage options and making new treatment more affordable are needed,” concluded the study authors.
Clinical Significance
“These findings are concerning, especially as ICIs are being use more frequently in treating people with both early- and late-stage cancers,” said Jingxuan Zhao, PhD, MPH, Senior Scientist in the Department of Surveillance and Health Equity Science at the American Cancer Society and lead author of this study, in a statement. “ICIs can be lifesaving; however, cancer patients without health insurance coverage may be unable to afford them due to their high costs.”
Dr. Zhao, of the American Cancer Society, is the corresponding author of this study.
Disclosure: For the study authors’ conflict of interest disclosures, visit jamanetwork.com.
