The Impact of Hospital Safety-Net Burden on Survival and Receipt of Chemoradiation in Anal Cancer Patients

Abstract

To determine if hospital safety-net burden impacts overall survival and delivery of care in patients with anal squamous cell carcinoma (SCC). The National Cancer Database (NCDB) was queried for patients diagnosed with anal SCC from 2004-2013. Hospitals were categorized based on the percentage of uninsured/Medicaid-insured patients treated at each facility, with hospitals in the 0-29th percentiles defined as no safety-net burden hospitals (NBH), hospitals in the 30-75th percentiles defined as low safety-net burden hospitals (LBH), and hospitals at the 75th percentile or above defined as high safety-net burden hospitals (HBH). Patient, facility, tumor, and treatment characteristics were compared using chi-squared analysis. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) were computed. Overall survival rates were estimated using the Kaplan-Meier method. Cox regression modeling was used to calculated crude and adjusted hazard ratios (aHR) with 95% CI. There were 298 HBH, 534 LBH, and 360 NBH identified with 4,669, 13,407, and 2,831 cases of anal cancer treated at each, respectively. The median percentage of uninsured/Medicaid patients treated was 31.3% (range 23.3-100%) at HBH, 11.5% (range 1.8-23.1%) at LBH, and 0% (range 0-0%) at NBH. Patients at HBH were more likely to be black or Hispanic, have incomes <$30,000, or have Stage III-IV disease (Table). Median follow-up in all patients was 39.3 months and 48.8 months in surviving patients. Five-year survival for anal cancer patients treated at HBH, LBH, and NBH was 65.5%, 71.2%, and 69.2%, respectively (p<0.0001). On univariate analysis, HBH was associated with worse survival vs. NBH (HR 1.16; 95% CI 1.04-1.29, p=0.009). On multivariate analysis adjusting for age, gender, race, Hispanic origin, insurance, income, education, comorbidities, stage, treatment modality, facility type, volume, and distance, there was no statistically significant difference in survival comparing HBH vs. NBH (aHR = 0.99; 95% CI 0.89-1.10, p=0.82). There was no difference in survival comparing LBH to NBH or HBH. For patients with Stage I-III anal cancer, odds of receiving chemoradiation did not vary by safety-net burden (HBH vs. NBH: aOR 1.04; 95% CI 0.93-1.17, p=0.46; LBH vs. NBH: aOR 0.98; 95% CI 0.89-1.08, p=0.62). High safety-net burden hospitals care for a higher proportion of anal cancer patients with underrepresented minority backgrounds, low income, and more advanced disease. Survival after anal cancer treatment and receipt of chemoradiation for Stage I-III disease were not significantly associated with hospital safety-net burden.Abstract 2366; Table 1Selected patient and tumor characteristics by hospital safety-net burden.NBHLBHHBHp-valueBlack race170 (6.0%)1340 (10.0%)770 (16.5%)<0.0001Hispanic109 (3.9%)564 (4.2%)391 (8.4%)<0.0001Income <$30,000241 (8.5%)1685 (12.6%)1049 (22.5%)<0.0001Stage III-IV868 (30.7%)4311 (32.2%)1684 (36.1%)<0.0001 Open table in a new tab