Patients with Medicaid, No Insurance See Smaller Added Benefits from Experimental Therapies

Patients with Medicaid or no insurance may have less added benefits from experimental therapies compared with standard treatments in clinical trials according to a study published in JAMA Network Open.¹

Given these findings, researchers suggested that a better understanding of the quality of survivorship care that patients with suboptimal insurance receive, including supportive care and posttreatment care, could help determine how external factors may impact outcomes for these patients.

“In general, our findings highlight the importance of coverage expansion policies for those with suboptimal insurance and underline the importance of improved coverage provisions for those with existing Medicaid insurance,” the authors wrote.

In this cohort study of pooled patient-level data from 19 trials in the SWOG Cancer Research Network from 1985 onward, researchers identified 10,804 patients with reportedly superior overall survival who were randomized to experimental treatment. Interaction tests were then used to evaluate whether hazard ratios (HRs) for death comparing standard group vs experimental group treatments were correlated with age (65 vs <65 years), race/ethnicity (minority vs nonminority populations), sex, or insurance status among patients younger than 65 years (Medicaid or no insurance vs private insurance) in multivariable Cox regression frailty models. Progression- or relapse-free survival was also assessed.

Ultimately, there was evidence of added survival benefits which correlated with receiving experimental therapy for all groups except for patients with Medicaid or no insurance (HR, 1.23; 95% CI, 0.97-1.56; P = 0.09) compared with those with private insurance (HR, 1.66; 95% CI, 1.44-1.92; P < 0.001; P = 0.03 for interaction).

Moreover, receipt of experimental treatment was associated with a reduction in added overall survival benefits in patients 65 years or older (HR, 1.21; 95% CI, 1.11-1.32; P < 0.001) compared with patients younger than 65 years (HR, 1.41; 95% CI, 1.30-1.53; P < 0.001; P = 0.01 for interaction), although both older and younger patients seemed to strongly benefit from receipt of experimental treatment.

Additionally, the progression- or relapse-free survival HRs did not vary by age, sex, or race/ethnicity, but did, however, differ between patients with Medicaid or no insurance (HR, 1.32; 95% CI, 1.06-1.64; P = 0.01) vs private insurance (HR, 1.74; 95% CI, 1.54-1.97; P < 0.001; P = 0.03 for interaction).

“Importantly, the present study did not indicate that patients with [Medicaid or no insurance] did not benefit from cancer therapy,” the authors wrote. “Rather, it showed that the added benefits associated with experimental therapies in clinical trials on [overall survival] were much smaller for patients with [Medicaid or no insurance] compared with privately insured patients.”

According to the study authors, confirmatory analyses in independent studies may provide necessary insights about the associations observed in this study.

In an editorial written by Rebecca A. Snyder, MD, MPH, of the Brody School of Medicine at East Carolina University, and George J. Chang, MD, MS, of MD Anderson Cancer Center, it was suggested that, based on the original study findings, clinical trials should also be studying patient interactions with healthcare personnel, rather than strictly focusing clinical trials on patient interactions with treatment regimens.²

“If the underinsured patient population cannot derive an equal survival benefit from experimental therapies, perhaps we need to refocus our resources on cancer care delivery research that studies the patient’s interaction not only with a treatment regimen but also with their caregivers, communities, treatment teams, and health care systems,” the editorial authors wrote. “To eliminate cancer health disparities, studies should address the other social determinants of health that are associated with cancer and noncancer survival for these at-risk patient populations.”

References:
1. Unger JM, Blanke CD, LeBlanc M, Barlow WE, Vaidya R, Ramsey SD, Hershman DL. Association of Patient Demographic Characteristics and Insurance Status With Survival in Cancer Randomized Clinical Trials With Positive Findings. JAMA Network Open. doi:10.1001/jamanetworkopen.2020.3842.
2. Snyder RA, Chang GJ. Insurance Status as a Surrogate for Social Determinants of Helath in Cancer Clinical Trials. JAMA Network Open. doi:10.1001/jamanetworkopen.2020.3890.

References:

1. Unger JM, Blanke CD, LeBlanc M, Barlow WE, Vaidya R, Ramsey SD, Hershman DL. Association of Patient Demographic Characteristics and Insurance Status With Survival in Cancer Randomized Clinical Trials With Positive Findings. JAMA Network Open. doi:10.1001/jamanetworkopen.2020.3842.

2. Snyder RA, Chang GJ. Insurance Status as a Surrogate for Social Determinants of Helath in Cancer Clinical Trials. JAMA Network Open. doi:10.1001/jamanetworkopen.2020.3890.