Abstract
BackgroundNumerous studies across a variety of malignancies have demonstrated that health insurance status is associated with differences in clinical presentation, type of treatments received, and survival. The effect of insurance status on the management of soft tissue sarcoma is unknown. We assessed the association of insurance on (a) stage at diagnosis, (b) receipt of neoadjuvant/adjuvant radiation therapy, and (c) overall survival (OS) in patients with soft tissue sarcoma.MethodsThe study cohort was identified from the National Cancer Database (NCDB) and consisted of patients with stage I‐IV soft tissue sarcoma of various histologies diagnosed from 2004 to 2015. The patients were stratified by age (<65 and ≥65 years) and by insurance status (commercial, Medicare, Medicaid and uninsured). Using multivariable logistic regression analysis, we evaluated the association between insurance status and (a) stage at diagnosis (Stage I‐III vs IV), and (b) receipt of neoadjuvant/adjuvant radiation therapy in patients with locally advanced disease. The association of insurance status on OS was assessed using Kaplan‐Meier and multivariable Cox proportional hazards analyses. A propensity score matched survival analysis was performed to account for measured confounders.Results49 754 patients were identified of whom 23 677 (48%) had commercial insurance, 20 867 (42%) had Medicare, 3229 (6%) had Medicaid, and 1981 (4%) were uninsured. In patients <65 years, those with Medicaid (OR = 1.74, 95% CI: 1.57‐1.93, P < .001) and the uninsured (OR = 1.71, 95% CI: 1.51‐1.94, P < .001) were more likely to present with stage IV vs Stage I‐III disease. Furthermore, among patients with locally advanced disease treated with limb sparing surgery, those with Medicaid (OR = 0.87, 95% CI: 0.77‐ 0.98, P = .021) and the uninsured (OR = 0.73, 95% CI: 0.63‐0.85, P < .001) were less likely to receive neoadjuvant or adjuvant radiotherapy as compared to those with commercial insurance. Lastly, having Medicaid (HR = 1.26, 95% CI: 1.17‐1.34, P < .001) and no insurance (HR = 1.30, 95% CI: 1.20‐1.41, P < .001) was associated with worse OS compared to having commercial insurance, a finding which remained significant after propensity score matching. In contrast, in patients ≥65 years, there were no statistically significant differences between those with Medicare and commercial insurance with regards to disease presentation, receipt of radiotherapy, or survival.ConclusionsIn a large modern cohort identified from the NCDB, commercial insurance status in patients <65 years was associated early diagnosis, receipt of neoadjuvant/adjuvant radiation therapy, and overall survival for patients with soft tissue sarcoma. Further efforts are warranted to understand disparities in care based on health insurance in the United States.
Highlights
Soft tissue sarcomas (STS) are rare tumors representing less than 1 percent of all newly diagnosed cancers in the United States.[1]
The study population was identified from the National Cancer Database (NCDB), a national cancer registry jointly sponsored by the American College of Surgeons and the American Cancer Society that draws upon hospital registry data from more than 1500
In both age cohorts (< and ≥65 years), we evaluated the association between insurance status and three primary endpoints, namely (a) stage at diagnosis (Stage I‐III vs Stage IV), (b) receipt of neoadjuvant or adjuvant radiation therapy for locally advanced STS patients (Stage II/III and non‐metastatic node positive Stage IV) who underwent limb sparing surgery, and (c) overall survival (OS)
Summary
Soft tissue sarcomas (STS) are rare tumors representing less than 1 percent of all newly diagnosed cancers in the United States.[1]. A National Cancer Database (NCDB) study, analyzing data from 15 957 patients with STS showed that guideline adherent treatment was associated with improved survival outcomes.[2]. Studies from several disease sites have shown that health insurance coverage influences receipt of guideline recommended care, timely treatment, as well as participation in clinical trials.[3] For instance, a recent study evaluating the impact of insurance coverage on outcomes of patients with breast sarcoma showed that Medicaid and uninsured patients were more likely to present with advanced disease and have worse outcomes as compared to privately insured patients.[4] Other studies in adult patients with STS have demonstrated that noncommercial insurance is associated with a longer time to treatment initiation[5] and a lower likelihood of receiving guideline concordant care[2] as compared to privately insured patients. The aim of this study was to utilize the NCDB to evaluate the association between insurance status and (a) stage of disease at diagnosis, (b) receipt of neoadjuvant or adjuvant radiation and (c) overall survival (OS) among patients diagnosed with STS
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