Abstract
Strides to improve survival in metastatic melanoma have been made with the use of immunotherapeutic agents in the form of immune checkpoint inhibitors. To examine the factors associated with immunotherapy receipt in patients with metastatic melanoma in the era of immune checkpoint inhibitors and the Patient Protection and Affordable Care Act. This cohort study used data on 9882 patients with metastatic melanoma diagnosed from January 1, 2013, to December 31, 2016, from the National Cancer Database. Patients who did not have documentation regarding immunotherapy receipt were excluded. Data analysis was performed from July 1, 2019, to December 15, 2019. Receipt of immunotherapy. The primary outcome was the association of receipt of immunotherapy as first-line therapy with sociodemographic factors. The secondary outcome was overall survival by receipt of immunotherapy. A total of 9512 patients (mean [SD] age, 65.1 [14.4] years; 6481 [68.1%] male; 9217 [96.9%] White) met the criteria for treatment analysis. A total of 3428 (36.0%) received immunotherapy, and 6084 (64.0%) did not. Increasing age (odds ratio [OR], 0.98; 95% CI, 0.97-0.98; P < .001) and increasing Charlson-Deyo comorbidity index (OR, 0.86; 95% CI, 0.80-0.92; P < .001) were associated with lower odds of receiving immunotherapy on regression analysis. Diagnosis in Medicaid expansion states (OR, 1.16; 95% CI, 1.05-1.27; P = .003), treatment at an academic or integrated cancer network program (OR, 1.59; 95% CI, 1.45-1.75; P < .001), and residence within the highest quartile of high school graduation rate zip code area (OR, 1.31; 95% CI, 1.09-1.56; P = .003) were associated with an increased likelihood of receiving immunotherapy. Median overall survival was 10.1 months (95% CI, 9.6-10.6 months) among all patients. Patients who received first-line immunotherapy had a median overall survival of 18.4 months (95% CI, 16.6-20.1 months) compared with 7.5 months (95% CI, 7.0-7.9 months) (P < .001) among patients who did not. In this cohort study, patients who received immunotherapy for metastatic melanoma had improved overall survival. Residence in Medicaid expansion states, younger age, low comorbidity index, care at academic medical centers or integrated network cancer programs, and residence in zip codes within the highest quartile of high school graduation were associated with an increased likelihood of receiving immunotherapy. Recognizing sociodemographic associations with treatment receipt is important to identify potential barriers to treatment.
Highlights
The mainstay treatment for unresectable or metastatic melanoma is systemic therapy
Diagnosis in Medicaid expansion states (OR, 1.16; 95% CI, 1.05-1.27; P = .003), treatment at an academic or integrated cancer network program (OR, 1.59; 95% CI, 1.45-1.75; P < .001), and residence within the highest quartile of high school graduation rate zip code area (OR, 1.31; 95% CI, 1.09-1.56; P = .003) were associated with an increased likelihood of receiving immunotherapy
Residence in Medicaid expansion states, younger age, low comorbidity index, care at academic medical centers or integrated network cancer programs, and residence in zip codes within the highest quartile of high school graduation were associated with an increased likelihood of receiving immunotherapy
Summary
The mainstay treatment for unresectable or metastatic melanoma is systemic therapy. Before the introduction of immune checkpoint inhibitors (ICIs), the standard of care for most patients with metastatic melanoma was dacarbazine administered as single-agent therapy or part of combination therapy.[1,2] Immunotherapy with high-dose interleukin 2 showed durable response in a few patients but was associated with significant toxic effects[2,3]; immunotherapeutic agents in the form of ICIs, including ipilimumab, nivolumab, and pembrolizumab, have substantially improved outcomes and become the standard of care for metastatic melanoma during the past decade.[4]After the landmark study of the cytotoxic T-lymphocyte–associated protein 4 inhibitor ipilimumab by Hodi et al,[5] ipilimumab became the first ICI approved for metastatic melanoma in 2011.6 Subsequently, single-agent anti–programmed cell death protein 1 agents have shown superior efficacy compared with ipilimumab, including pembrolizumab in KEYNOTE-006 (Study to Evaluate the Safety and Efficacy of Two Different Dosing Schedules of Pembrolizumab [MK-3475] Compared to Ipilimumab in Participants With Advanced Melanoma)[7,8,9] and nivolumab in CHECKMATE-066 (Study of Nivolumab [BMS-936558] Compared With Dacarbazine in Untreated, Unresectable, or Metastatic Melanoma).[10,11] Combination therapy with nivolumab and ipilimumab showed improved overall survival,[12,13,14] leading to approval of the combination in the first-line setting.[11,15]Despite the improvement in outcomes with ICIs for metastatic melanoma, previous studies[16,17] have found that sociodemographic health disparities are associated with limited access to effective therapies for melanoma, including immunotherapy. Before the introduction of immune checkpoint inhibitors (ICIs), the standard of care for most patients with metastatic melanoma was dacarbazine administered as single-agent therapy or part of combination therapy.[1,2] Immunotherapy with high-dose interleukin 2 showed durable response in a few patients but was associated with significant toxic effects[2,3]; immunotherapeutic agents in the form of ICIs, including ipilimumab, nivolumab, and pembrolizumab, have substantially improved outcomes and become the standard of care for metastatic melanoma during the past decade.[4]. Use of systemic therapy has been administered more frequently to those who were living in high-income areas, younger individuals, and married individuals.[19]
Sign-in/Register to view highlights & summary Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
