Disparities in use of immunotherapy for stage III and IV melanoma patients.

Abstract

e19087 Background: Approval of immune checkpoint inhibitors (ICIs), ipilimumab (ipi), nivolumab and pembrolizumab has significantly changed the outcome for patients with stage III and IV melanoma. Adoption of ICI based immunotherapy (IT) and utilization has not been studied. We sought to assess the utilization of ICI therapy and identify barriers that limit access. Methods: The National Cancer Database (2004-2016) was used to analyze stage III and IV melanoma patients separately using descriptive statistics, univariable and multivariable models to compare use of IT (yes/no) with sex, race, age, Charlson-Deyo score, insurance status, census median income, census education, distance to treating facility, year of diagnosis and facility type. Results: Of 15,373 stage III patients 2,555 (16.6%) received IT. Since approval of ipi for resected stage III disease, 20.8% received adjuvant treatment in 2015 and 28.2% in 2016 (Table). Multivariable analysis showed that older patients (OR 0.96 (0.96-0.97)), those treated at non-academic programs (community cancer (CC) (OR 0.69 (0.55-0.86)), comprehensive CC (OR 0.55 (0.49-0.70)), or integrated network cancer program (INCP) (OR 0.58 (0.49-0.70))), have government insurance (OR 0.80 (0.70-0.90)) or no insurance (OR 0.78 (0.64-0.94)) vs private insurance were significantly less likely to receive adjuvant IT. Of 21,718 stage IV patients, 3,098 (14.3%) received IT. Using multivariable analysis, patients with fewer co-morbidities (OR 1.4 (1.05-1.86)) diagnosed in 2011 or later (Table) were more likely to receive IT. Disparities were noted in older patients (OR 0.98 (0.97-0.98)), those treated at non-academic programs (CC program, OR 0.34 (0.28-0.41)), comprehensive CC program (OR 0.34 (0.30-0.38)), or INCP (OR 0.40 (0.34-0.46)), and low vs high education level (OR 0.75 (0.62-0.90)) as less likely to receive IT. Conclusions: Despite approval and significant impact of ICIs, many patients did not receive approved therapy. Variations in care depended on where patients received treatment, age, and education level. [Table: see text]