Top

Published in:

01-09-2020 | Neuroendocrine Tumor | Health Services Research and Global Oncology

Impact of Insurance Status on Survival in Gastroenteropancreatic Neuroendocrine Tumors

Authors: Paula Marincola Smith, MD, Jordan Baechle, BS, Marcus C. Tan, MD, Carmen C. Solórzano, MD, Alexandra G. Lopez-Aguiar, MD, Mary Dillhoff, MD, Eliza W. Beal, MD, George Poultsides, MD, John G. D. Cannon, MD, Flavio G. Rocha, MD, Angelena Crown, MD, Clifford S. Cho, MD, Megan Beems, MD, Emily R. Winslow, MD, Victoria R. Rendell, MD, Bradley A. Krasnick, MD, Ryan C. Fields, MD, Shishir K. Maithel, MD, Christina E. Bailey, MD, Kamran Idrees, MD, MSCI, MMHC

Published in: Annals of Surgical Oncology | Issue 9/2020

Abstract

Background

Insurance status predicts access to medical care in the USA. Previous studies have shown uninsured patients with some malignancies have worse outcomes than insured patients. The impact of insurance status on patients with gastroenteropancreatic neuroendocrine tumors (GEP-NETs) is unclear.

Patients and Methods

A retrospective cohort study of adult patients with resected GEP-NETs was performed using the US Neuroendocrine Tumor Study Group (USNETSG) database (2000–2016). Demographic and clinical factors were compared by insurance status. Patients ≥ 65 years were excluded, as these patients are almost universally covered by Medicare. Kaplan–Meier and log-rank analyses were used for survival analysis. Logistic regression was used to assess factors associated with overall survival (OS).

Results

The USNETSG database included 2022 patients. Of those, 1425 were aged 18–64 years at index operation and were included in our analysis. Uninsured patients were more likely to have an emergent operation (7.9% versus 2.5%, p = 0.01) and less likely to receive postoperative somatostatin analog therapy (1.6% versus 9.9%, p = 0.03). OS at 1, 5, and 10 years was significantly higher for insured patients (96.3%, 88.2%, and 73.8%, respectively) than uninsured patients (87.7%, 71.9%, and 44.0%, respectively) (p < 0.01). On Cox multivariate regression analysis controlling for T/M stage, tumor grade, ASA class, and income level, being uninsured was independently associated with worse OS [hazard ratio (HR) 2.69, 95% confidence interval (CI) 1.32–5.48, p = 0.006].

Conclusions

Insurance status is an independent predictor of survival in patients with GEP-NETs. Our study highlights the importance of access to medical care, disparities related to insurance status, and the need to mitigate these disparities.

Available only for authorised users

McDavid K, Tucker TC, Sloggett A, Coleman MP. Cancer survival in Kentucky and health insurance coverage. Arch Intern Med. 2003;163:2135-2144.CrossRef

Slatore CG, Au DH, Gould MK. An official American Thoracic Society systematic review: insurance status and disparities in lung cancer practices and outcomes. Am J Respir Crit Care Med. 2010;182(9):1195-1205. https://doi.org/10.1164/rccm.2009-038st.CrossRefPubMed

Niu X, Roche LM, Pawlish KS, Henry KA. Cancer survival disparities by health insurance status. Cancer Med. 2013;2(3):403-411. https://doi.org/10.1002/cam4.84.CrossRefPubMedPubMedCentral

Fedewa SA, Lerro C, Chase D, Ward EM. Insurance status and racial differences in uterine cancer survival: A study of patients in the National Cancer Database. Gynecol Oncol. 2011;122(1):63-68. https://doi.org/10.1016/j.ygyno.2011.03.010.CrossRefPubMed

Robbins AS, Pavluck AL, Fedewa SA, Chen AY, Ward EM. Insurance status, comorbidity level, and survival among colorectal cancer patients age 18 to 64 years in the National Cancer Data Base from 2003 to 2005. JCO. 2009;27(22):3627-3633. https://doi.org/10.1200/jco.2008.20.8025.CrossRef

DeRose YS, Gligorich KM, Wang G, et al. Patient-derived models of human breast cancer: protocols for in vitro and in vivo applications in tumor biology and translational medicine. Vol 100. Hoboken, NJ: Wiley; 2001:3983–52. https://doi.org/10.1002/0471141755.ph1423s60.

Kwok J, Langevin SM, Argiris A, Grandis JR, Gooding WE, Taioli E. The impact of health insurance status on the survival of patients with head and neck cancer. Cancer. 2010;116(2):476-485. https://doi.org/10.1002/cncr.24774.CrossRefPubMedPubMedCentral

Lee-Feldstein A, Feldstein PJ, Buchmueller T, Gale K. The relationship of HMOs, health insurance, and delivery systems to breast cancer outcomes. Med Care. 2000;38(7):705-718.CrossRef

Gorey KM. Breast cancer survival in Canada and the USA: meta-analytic evidence of a Canadian advantage in low-income areas. Int J Epidemiol. 2009;38(6):1543-1551. https://doi.org/10.1093/ije/dyp193.CrossRefPubMedPubMedCentral

10.

Gorey KM, Luginaah IN, Bartfay E, et al. Effects of socioeconomic status on colon cancer treatment accessibility and survival in Toronto, Ontario, and San Francisco, California, 1996–2006. Am J Public Health. 2010;101(1):112-119. https://doi.org/10.2105/ajph.2009.CrossRefPubMed

11.

Cohen RA, Martinez ME, Zammitti EP. Health insurance coverage: early release of estimates from the National Health Interview Survey, January - March 2017. National Center for Health Statistics. August 2017:1-34.

12.

Broder MS, Cai B, Chang E, Neary MP. Epidemiology of gastrointestinal neuroendocrine tumors in a us commercially insured population. Endocr Pract. 2017;(aop):EP171879.OR–27. https://doi.org/10.4158/ep171879.or.

13.

Rindi G, Petrone G, Inzani F. The 2010 WHO Classification of digestive neuroendocrine neoplasms: a critical appraisal four years after its introduction. Endocr Pathol. 2014;25(2):186-192. https://doi.org/10.1007/s12022-014-9313-z.CrossRefPubMed

14.

Strumolo A. Database of HPSA and low-income ZIP codes for issuers subject to the alternate ECP Standard for the purposes of QHP certification. March 2013:1-10. https://data.cms.gov/.

15.

Zhang JX, Huang ES, Drum ML, et al. Insurance status and quality of diabetes care in community health centers. Am J Public Health. 2009;99(4):742-747. https://doi.org/10.2105/ajph.2007.125534).CrossRefPubMedPubMedCentral

16.

Medford Davis LN, Fonarow GC, Bhatt DL, et al. Impact of insurance status on outcomes and use of rehabilitation services in acute ischemic stroke: findings from Get With The Guidelines-Stroke. J Am Heart Assoc. 2016;5(11):e004282–25. https://doi.org/10.1161/jaha.116.004282.CrossRefPubMedPubMedCentral

17.

Smith SA, Hasan AK, Binkley PF, Foraker RE. The impact of insurance and socioeconomic status on outcomes for patients with left ventricular assist devices. J Surg Res. 2014;191(2):302-308. https://doi.org/10.1016/j.jss.2014.05.004.CrossRefPubMedPubMedCentral

18.

Wolin EM. The expanding role of somatostatin analogs in the management of neuroendocrine tumors. Gastrointest Cancer Res. 2012;5(5):162-168.

19.

Hoskin TL, Boughey JC, Day CN, Habermann EB. Lessons learned regarding missing clinical stage in the National Cancer Database. Ann Surg Oncol. 2019;26(3):739-745. https://doi.org/10.1245/s10434-018-07128-3.CrossRefPubMed

20.

Helkin A, Jain SV, Gruessner A, et al. Impact of ASA score misclassification on NSQIP predicted mortality: a retrospective analysis. Perioper Med. 2017;6(23):1-6. https://doi.org/10.1186/s13741-017-0076-1.CrossRef

21.

Kaiser Family Foundation. Distribution of Nonelderly Uninsured by Family Work Status: 2014-2017. 2017:1-11. www.kff.org.

22.

Winkelman TNA, Segel JE, Davis MM. Medicaid enrollment among previously uninsured Americans and associated outcomes by race/ethnicity-United States, 2008-2014. James CV, ed. Health Serv Res. 2018;54(11):297-306. https://doi.org/10.1111/1475-6773.13085.

23.

Busch SH, Meara E, Huskamp HA, Barry CL. Characteristics of adults with substance use disorders expected to be eligible for Medicaid under the ACA. Psychiatr Serv. 2013;64(6):520-526. https://doi.org/10.1176/appi.ps.201200011).CrossRefPubMedPubMedCentral

24.

McMorrow S, Gates JA, Long SK, Kenney GM. Medicaid expansion increased coverage, improved affordability, and reduced psychological distress for low-income parents. Health Affairs. 2017;36(5):808-818. https://doi.org/10.1377/hlthaff.2016.1650.CrossRefPubMed

Title: Impact of Insurance Status on Survival in Gastroenteropancreatic Neuroendocrine Tumors
Authors: Paula Marincola Smith, MD
Jordan Baechle, BS
Marcus C. Tan, MD
Carmen C. Solórzano, MD
Alexandra G. Lopez-Aguiar, MD
Mary Dillhoff, MD
Eliza W. Beal, MD
George Poultsides, MD
John G. D. Cannon, MD
Flavio G. Rocha, MD
Angelena Crown, MD
Clifford S. Cho, MD
Megan Beems, MD
Emily R. Winslow, MD
Victoria R. Rendell, MD
Bradley A. Krasnick, MD
Ryan C. Fields, MD
Shishir K. Maithel, MD
Christina E. Bailey, MD
Kamran Idrees, MD, MSCI, MMHC
Publication date: 01-09-2020
Publisher: Springer International Publishing
Keyword: Neuroendocrine Tumor
Published in: Annals of Surgical Oncology / Issue 9/2020
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI: https://doi.org/10.1245/s10434-020-08359-z

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Impact of Insurance Status on Survival in Gastroenteropancreatic Neuroendocrine Tumors

Abstract

Background

Patients and Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Patients and Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 9/2020

Accuracy of Grading in Pancreatic Neuroendocrine Neoplasms and Effect on Survival Estimates: An Institutional Experience

An Odyssey into the Land of Deleterious Rare Mutations in Colorectal Liver Metastases

Virtual Interviews for the Complex General Surgical Oncology Fellowship: The Dana-Farber/Partners Experience

Prognostic Significance of Lymphatic, Venous and Perineural Invasion After Neoadjuvant Chemotherapy in Patients with Gastric Adenocarcinoma

Non-clinical Drivers of Variation in Preoperative MRI Utilization for Breast Cancer

Analysis of Surgical Trends for Axillary Lymph Node Management in Patients with Ductal Carcinoma In Situ Using the NSQIP Database: Are We Following National Guidelines?