Disparities in survival among patients with pancreatic neuroendocrine tumor using the national cancer database: effects of insurance status and treatment facility

Abstract

Background: Little is known regarding the impact of treating facility type on socioeconomic-driven survival disparities in patients with pancreatic neuroendocrine tumors (PNET). The primary aim of this study is to quantify disparities in overall survival (OS) associated with age, gender, race, insurance status and treatment facility type for patients with PNET. Methods: A retrospective cohort study was performed using the National Cancer Database. All patients with histologically confirmed PNET from 2004 to 2014 were included. Treatment facility were classified as community cancer center (CCC; 100-500 cases/year), comprehensive community cancer center (CPCC; >500 cases/year), academic hospital (AH; teaching hospital with >500 cases/year), or integrated network cancer center (INC; multi-center organization). Demographic and clinical factors were compared according to treatment facility type. Kaplan-Meier and log-rank analysis were used for survival analysis. Cox proportional hazard analyses were used to assess the impact of age, gender, race, insurance status, and treatment facility type on OS. Results: A total of 11,275 patients met inclusion criteria. The median age at diagnosis was 61. The majority of patients were white (83.2%), male (53.5%), and had private insurance (51.5%). 3.8% of patients received treatment at CCC, 27.1% at CPCC, 58.6% at AH, and 10.5% at INC. Increasing age was associated with worse OS. Females had improved OS compared to males (100.4 months vs 79.2 months, P < 0.001). Patients with private insurance had improved OS compared to patients with other insurance (112 months vs 65.6 months, P<0.001). Median OS was 30.6 months for patients treated at CCC, 56.7 months for CPCC, 109.8 months for AH, and 90.7 months for INC (P < 0.001) [Figure 1]. There was no difference in OS according to race. On multivariable analysis, increasing age was associated with worse OS (Hazard ratio [HR] 1.08, 95% confidence interval [CI] 1.06-1.09, P < 0.001). Females had improved OS compared to males (HR 0.90, 95% CI 0.87-0.95, P<0.001). In comparison to private insurance, patients with Medicaid (HR 1.25, 95% CI 1.13-1.39, P<0.001) and other insurance (HR 1.12, 95% CI 1.06-1.18, P<0.001) had worse OS. Patients treated at an AH also had improved OS compared to treatment at CCC (HR 1.23, 95% CI 1.11-1.37, P < 0.001), CCCP (HR 1.22, 95% CI 1.16-1.29, P < 0.001) and INC (HR 1.26, 95% CI 1.16-1.36, P < 0.001). Gender (Pinteraction = 0.6313) and insurance disparities (Pinteraction = 0.5661) were not mitigated according to type of treating facility whereas age-related disparities (Pinteraction = 0.015) were slightly diminished by treatment at non-AH. Conclusion: Younger age, female sex, private insurance and treatment at AH were independently associated with improved OS in patients with PNET. Gender-based and insurance-based survival disparities were not mitigated by treatment at an AH. Conversely, age-based disparities were diminished for patients treated at non-AH.