The introduction of immune checkpoint inhibitors (ICIs) widened survival disparities between privately insured and uninsured patients with advanced melanoma and NSCLC, despite improving outcomes across all insurance groups. Medicaid patients experienced similar survival improvements to privately insured patients, suggesting Medicaid expansion could help reduce these disparities for uninsured individuals.
Study Design & Population
Retrospective cross-sectional analysis using National Cancer Database (NCDB)
- 183,440 patients aged 18-64 with stage IV cancer (2002-2019)
- Cancer types: melanoma (n=12,048), non-small cell lung cancer (NSCLC) (n=152,610), renal cell carcinoma (RCC) (n=18,782)
- Insurance distribution: 65.0% private, 24.1% Medicaid, 10.9% uninsured
- Mean age: 55.5 years, 56.5% male
Key Findings
Melanoma (post-ICI approval):
- Uninsured patients: 16.2% → 28.3% 2-year survival
- Private insurance: 28.7% → 46.0% 2-year survival
- Widened disparity: 6.1 percentage points (95% CI: 1.7-10.6)
NSCLC (post-ICI approval):
- Survival gap widened: 1.3 percentage points between uninsured vs. privately insured (95% CI: 0.2-2.3)
Medicaid vs. Private Insurance:
- No significant widening of disparities across all three cancer types
- Similar survival improvements between groups
Clinical Implications
- Uninsured patients may face barriers to accessing high-cost ICIs despite FDA approval
- Medicaid coverage appears protective, suggesting expansion could improve outcomes for uninsured patients
- Financial assistance programs and patient navigation may be necessary to ensure equitable ICI access
- Geographic disparities likely to worsen in non-Medicaid expansion states
Limitations
- Insurance status measured only at diagnosis – coverage changes unknown
- All-cause mortality used as proxy for cancer-specific survival
- No data on actual ICI receipt – analysis reflects population-level effects
- Limited to three cancer types with adequate post-approval follow-up
- Potential confounding from concurrent treatment advances
Source: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2836042