Medicaid Not Associated with Improved Survival in Patients with SCLC

April 30, 2020

These findings suggest that there are significant outcome inequalities for patients with small cell lung cancer which are relevant to the policy debate on Medicaid expansion under the Affordable Care Act.

In a study published in JAMA Oncology, Medicaid was not found to be associated with improved survival in patients with small cell lung cancer (SCLC) compared with being uninsured. 

These findings suggest that there are significant outcome inequalities for SCLC which are relevant to the policy debate on Medicaid expansion under the Affordable Care Act.

“This study intentionally focused on patients with SCLC because they are often economically disadvantaged, but require timely access to high-quality multidisciplinary care, making them disproportionately vulnerable to poor outcomes,” the authors wrote. 

Patients in this cohort study included adult patients with limited-stage (LS) and extensive-stage (ES) SCLC from the US National Cancer Database (NCDB) from 2004 to 2013. Patients were evaluated with respect to insurance status, and association of insurance status with survival were determined using univariate analyses, multivariable analyses, and propensity score matching.

Overall, 70,247 (38.6%) patients with LS-SCLC and 109,479 (60.2%) patients with ES-SCLC were identified for the study. On univariate analyses of patients with LS-SCLC, Medicaid coverage was not associated with a survival advantage compared with being uninsured (HR, 1.02; 95% CI, 0.96-1.08; = 0.49). Similarly, on multivariable analyses of patients with ES-SCLC, compared with being uninsured, Medicaid coverage was not associated with a survival advantage (HR, 1.00; 95% CI, 0.96-1.03; = .78). 

Further, following propensity score matching, median survival was found to be similar between the uninsured and Medicaid groups both among patients with LS-SCLC (14.4 vs 14.1 months; HR, 1.05; 95% CI, 0.98-1.12; = 0.17) and those with ES-SCLC (6.3 vs 6.4 months; HR, 1.00; 95% CI, 0.96-1.04; = 0.92). 

Notably, the researchers suggested that the disparate outcomes in SCLC can be partially explained by multiple patient-related factors, including race/ethnicity, income, comorbidities, education, and insurance status. Additionally, it is known that low-income individuals generally experience disparate outcomes in cancer care and that Medicaid recipients tend to present with more advanced-stage disease. However, the inferior outcomes observed in this patient population appeared to persist even after controlling for cancer stage.

“There are a number of factors that may explain the apparent lack of efficacy of Medicaid coverage in SCLC, including higher out-of-pocket drug expenses, limited access to clinical trials, reduced reimbursement, and lengthy processing delays that can be particularly devastating for a cancer with an aggressive histologic profile, such as SCLC,” the authors wrote.

Factors not captured in the NCDB that may have provided additional insight into the researcher’s findings include clinical trial participation, smoking status, tumor biology, radiation fractionation, chemotherapy dosage, and radiation treatment delays and compliance.

“Although the Medicaid program has expanded under the Affordable Care Act in an attempt to improve access to care, additional policy work is needed to improve cancer outcomes for the uninsured and Medicaid populations with SCLC,” the authors wrote.

Reference:

Pezzi TA, Schwartz DL, Pisters KMW, et al. Association of Medicaid Insurance With Survival Among Patients With Small Cell Lung Cancer. JAMA Network Open. doi:10.1001/jamanetworkopen.2020.3277.