Abstract
Small cell lung cancer (SCLC) is an aggressive neoplasm requiring rapid access to subspecialized multidisciplinary care. For this reason, insurance coverage such as Medicaid may be associated with oncologic outcomes in this disproportionately economically vulnerable population. With Medicaid expansion under the Affordable Care Act, it is important to understand outcomes associated with Medicaid coverage among patients with SCLC. To determine the association of Medicaid coverage with survival compared with other insurance statuses. This cohort study included adult patients with limited-stage (LS) and extensive-stage (ES) SCLC in the US National Cancer Database from 2004 to 2013. Data were analyzed in January 2019. Patients were analyzed with respect to insurance status. Associations of insurance status with survival were interrogated with univariate analyses, multivariable analyses, and propensity score matching. A total of 181 784 patients with SCLC (93 131 [51.2%] female; median [interquartile range] age; 67 [60-75] years for patients with LS-SCLC and 68 [60-75] years for patients with ES-SCLC) were identified, of whom 70 247 (38.6%) had LS-SCLC and 109 479 (60.2%) had ES-SCLC. On univariate analyses of patients with LS-SCLC, Medicaid coverage was not associated with a survival advantage compared with being uninsured (hazard ratio, 1.02; 95% CI, 0.96-1.08; P = .49). Likewise, on multivariable analyses of patients with ES-SCLC, compared with being uninsured, Medicaid coverage was not associated with a survival advantage (hazard ratio, 1.00; 95% CI, 0.96-1.03; P = .78). After propensity score matching, median survival was similar between the uninsured and Medicaid groups both among patients with LS-SCLC (14.4 vs 14.1 months; hazard ratio, 1.05; 95% CI, 0.98-1.12; P = .17) and those with ES-SCLC (6.3 vs 6.4 months; hazard ratio, 1.00; 95% CI, 0.96-1.04; P = .92). Despite of billions of dollars in annual federal and state spending, Medicaid was not associated with improved survival in patients with SCLC compared with being uninsured in the US National Cancer Database. These findings suggest that there are substantial outcome inequalities for SCLC relevant to the policy debate on the Medicaid expansion under the Affordable Care Act.
Highlights
Small cell lung cancer (SCLC) is a highly aggressive neoplasm representing 15% to 30% of lung cancers.[1]
On univariate analyses of patients with LS-SCLC, Medicaid coverage was not associated with a survival advantage compared with being uninsured
On multivariable analyses of patients with ES-SCLC, compared with being uninsured, Medicaid coverage was not associated with a survival advantage
Summary
Small cell lung cancer (SCLC) is a highly aggressive neoplasm representing 15% to 30% of lung cancers.[1] For both limited-stage (LS) and extensive-stage (ES) SCLC, access to multidisciplinary care is crucial to optimize tumor control and improve survival. In LS-SCLC, combined modality therapy with concurrent chemotherapy and thoracic radiation therapy have long been demonstrated to improve survival.[2] Multidisciplinary care has been proven to play a crucial role in ES-SCLC where cytotoxic chemotherapy,[3] thoracic radiotherapy,[4] and PD-1/PD-L1–directed immunotherapy provide a survival benefit.[5]. Despite the benefits of multidisciplinary care in SCLC, barriers to combined modality therapy in the US, such as government insurance coverage,[6,7] have been identified. Medicaid is a joint federaland state-funded program designed to provide health insurance coverage for low-income populations. At least in part as a result of lower reimbursement,[12] access to specialized outpatient care has been shown to be limited by Medicaid coverage in children and adults.[13,14,15]
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