Do Health Insurance and Other Psychosocioeconomic Determinants of Health Impact Survival Through Treatment Delays with Stereotactic Body Radiation Therapy in Borderline Resectable and Locally Advanced Pancreatic Cancer Patients?

Abstract

The biopsychosocial model of health suggests that focusing only on the biologics of disease neglects areas for improvement that may affect outcomes. Costs of stereotactic body radiation therapy (SBRT) for borderline resectable (BRPC) and locally advanced (LAPC) pancreatic cancer may be prohibitive for insurance companies to approve in a timely fashion given the debated necessity of neoadjuvant SBRT. We hypothesized that psychosocioeconomic factors contribute to delayed initiation of SBRT, which leads to poor survival outcomes. Retrospective analysis of an IRB approved database of BRPC and LAPC patients treated with SBRT yielded 223 patients that met our selection criteria from 2009-2016. Patients were treated according to an institutional treatment pathway, with systemic therapy regimens based on the discretion of the treating medical oncologist consisting of either gemcitabine-based regimens or FOLFIRINOX. This was followed by 5 fraction SBRT. All patients undergoing SBRT were assessed for psychosocial needs prior to therapy. Delayed initiation of SBRT was defined as >21 days from the end of chemotherapy to the first day of SBRT. Delayed start of SBRT (18.4 vs 12.0 months, p<0.001), no secondary insurance prior to SBRT treatment (12.0 vs 16.5 months, p=0.009), and no reliable transportation (11.5 vs 15.0 months, p=0.045) were all independently associated with poor overall survival. Delayed SBRT starts were associated with not having private insurance (p=0.005), not having United (p=0.020), having financial concerns (p=0.041), and living in a lower valued home (p=0.008). Proxies of lower socioeconomic status are associated with delayed SBRT starts, which, in this cohort, is also tied to poor overall survival. As stewards of the healthcare system, it is imperative for clinicians to holistically assess patients that may be vulnerable to these non-biologic factors, as this may impede time sensitive treatments. Referral for radiation oncology evaluation prior to or shortly after initiation of systemic therapy may allow earlier identification of these factors so that these issues can be addressed proactively, mitigating potential delays in SBRT delivery.