Worse outcomes associated with public insurance at sarcoma diagnosis in adolescent and young adults (AYAs).

Abstract

e18143 Background: Studies have shown that having public or no insurance at sarcoma diagnosis is associated with higher stage disease and poor survival. However, previous studies have not differentiated sarcoma patients who enrolled in Medicaid at diagnosis from those previously insured, groups with differing access to care. Therefore, we examined the impact of insurance on stage at diagnosis and overall survival for AYAs with soft tissue sarcoma (STS), osteosarcoma (OS) and Ewing sarcoma (EWS). Methods: Using Medicaid enrollment data linked to the California Cancer Registry, we identified AYAs with STS (n = 1782), OS (n = 458), and EWS (n = 348), diagnosed during 2005-14. Insurance was classified as Medicaid [1. Continuous (≥5 months prior to diagnosis), 2. Discontinuous, 3. At diagnosis (no coverage prior to diagnosis)], private, and uninsured. Logistic and Cox proportional hazards regression determined the association of insurance with metastatic stage (vs localized) and overall survival, respectively adjusting for sociodemographic factors, baseline comorbidities, type of facility, treatment (survival) and stage (survival). Results: Only 17.5% of sarcoma patients had continuous Medicaid prior to diagnosis, with 11% of STS, 17% of EWS and 19% of OS patients obtaining Medicaid at diagnosis. AYAs with Medicaid at diagnosis [Odds Ratio (OR) 3.03, 95% Confidence Interval (CI) 2.27-4.03; vs private] and discontinuous Medicaid (OR 2.25, CI 1.48-3.41) had a higher likelihood of metastatic disease. STS patients with Medicaid at diagnosis [Hazard Ratio (HR) 1.83, CI 1.44-2.33; vs private) and discontinuous Medicaid (HR 1.45, CI 1.01-2.08) had worse survival. Medicaid at diagnosis (HR 1.68, CI 1.07-2.63) also was associated with worse survival in OS patients, but this association was not observed in EWS patients. Conclusions: Lacking insurance prior to diagnosis is associated with metastatic disease at presentation and worse survival in AYA patients with sarcoma. Health insurance remained associated with worse survival even after adjusting for stage, highlighting the importance of continuous health insurance to improve outcomes for this patient population.