Sociodemographic Factors Suggest Barriers to Care for Patients with Metastatic Melanoma

Immunotherapy is becoming a wider treatment option for patients with metastatic melanoma; however, it is more likely that patients with favorable sociodemographic factors will receive immunotherapy for their disease in comparison to other patients.

In an analysis of a cohort study of 9,512 patients, published in JAMA Network Open, researchers found that patients were more likely to be treated with immunotherapy if they were diagnosed in a Medicaid expansion state, treated at an academic or integrated cancer center, or live in an area with a high graduation rate. All these factors show a sociodemographic association with immunotherapy treatment that suggests a barrier of care for patients less likely to live and receive treatment in these areas.

“Despite the improvement in outcomes with (immune checkpoint inhibitors) for metastatic melanoma, previous studies have found that sociodemographic health disparities are associated with limited access to effective therapies for melanoma, including immunotherapy,” the authors wrote. “Insurance status is also associated with stage of diagnosis, with uninsured patients presenting at more advanced disease stages compared with privately insured patients.”

Utilizing data from the National Cancer Database, a nationwide oncology outcomes database for over 1,500 accredited cancer programs, researchers looked at the association of patients receiving immunotherapy as first line treatment and their sociodemographic factors as the primary outcome. For instance, uninsured patients or those with Medicaid were less likely to receive immunotherapy in comparison to those with private insurance. Those diagnosed in states with expanded programs also had a stronger likelihood of receiving immunotherapy.

The secondary outcome was overall survival in patients that received immunotherapy. Researchers found a median overall survival of 10.1 months for all patients, regardless of treatment, but patients who received immunotherapy as a first line treatment had a median overall survival of 18.4 months compared to 7.5 months in patients who did not receive the treatment.

Only 36% of the study population received immunotherapy. Patients diagnosed in non-Medicaid expansion states had a median of 54 days till receiving immunotherapy in comparison to 52 days in expansion states. Moreover, researchers found the most significant association for patients receiving immunotherapy when comparing patients who received immunotherapy at an academic cancer center, or integrated network cancer program, to a community cancer center, or comprehensive community cancer program.

“Care at academic centers may allow for access to experts well versed in treating patients with newer therapies and managing their complications,” researchers explained.

Of the 3,377 patients who received treatment at comprehensive community cancer programs, 991 received immunotherapy as a first line treatment. In comparison, of the 3,684 patients who received treatment at an academic or research program 1,578 received immunotherapy as a first line treatment.

“The present study adds to the increasing literature indicating that sociodemographic disparities are associated with patients’ access to health care,” the authors concluded. “Specifically, this study of NCDB data is the first, to our knowledge, to find an increased likelihood of receiving a specific category of treatment (immunotherapy) in patients diagnosed with stage 4 melanoma in Medicaid expansion states.”