Racial disparities and insurance status: An epidemiological analysis of Ohio melanoma patients

Current Patterns of Treatment and Outcomes in Advanced Melanoma at a Single Institution

INTRODUCTION

Treatment of advanced melanoma has been transformed by novel systemic therapies. The purpose of this study is to describe the current utilization patterns of immunotherapies with respect to survival outcomes in advanced melanoma.

METHODS

We performed a retrospective cohort study of patients with Stage 3 and 4 melanoma at our institution (2009-2019). Primary outcomes included overall survival (OS) and progression free survival (PFS). Kaplan-Meier survival analysis and Cox proportional hazards regression analysis evaluated associations between covariates and survival outcomes.

RESULTS

Of 244 patients, 5-y OS was 62.4%. Lymphovascular invasion (hazard ratio [HR] = 2.462, P = 0.030) was associated with shorter PFS whereas female gender (HR = 0.324, P = 0.010) was associated with longer PFS. Residual tumor (HR = 146, P = 0.006) and Stage 4 disease (HR = 3.349, P = 0.011) were associated with shorter OS. Use of immunotherapy increased from 2% to 23% over the study period, and use of neoadjuvant immunotherapy also increased up to 2016. Timing of immunotherapy administration was not significantly associated with survival. Of the 193 patients who received 2 or more treatment types, the most common treatment sequence was surgery followed by immunotherapy (n = 117, 60.6%).

CONCLUSIONS

Immunotherapy is increasingly used for treatment of advanced melanoma. In this heterogeneous cohort, there was no significant association between timing of immunotherapy and survival outcomes.

Melanoma in skin of color: Part II. Racial disparities, role of UV, and interventions for earlier detection

Despite a higher incidence of melanoma among White individuals, melanoma-specific survival is worse among individuals with skin of color. Racial disparities in survival are multifactorial. Decreased skin cancer education focused on people with skin of color, lower rates of screening, increased socioeconomic barriers, higher proportions of more aggressive subtypes, and underrepresentation in research and professional education contribute to delays in diagnosis and treatment. Although high, intermittent UV exposure during childhood has been established as a significant modifiable risk factor for melanoma in individuals with lighter skin phototypes, there are limited data on UV exposure and melanoma risk in people with darker skin phototypes. The second article of this continuing medical education series will examine factors contributing to racial disparities in melanoma-specific survival, discuss the role of UV radiation, and address the need for further research and targeted educational interventions for melanoma in individuals with skin of color.

Demographic Characteristics Influence Treatment Costs of Invasive Melanoma in Florida

BACKGROUND

Demographic characteristics are known to influence the treatment and outcomes of patients with invasive melanoma. Whether these characteristics influence treatment costs is unknown. We aimed to analyze whether patient demographics and tumor characteristics influence treatment costs for patients with invasive cutaneous melanoma in Florida.

METHODS

This was a cross-sectional study in which the Florida Inpatient and Outpatient Dataset of the Agency for Health Care Administration was analyzed for patients with a diagnosis of invasive melanoma between January 1, 2013 and December 31, 2018. Categorical variables were assessed using Pearson χ2 tests, and continuous variables were evaluated using Kruskal-Wallis tests. Logistic regression analysis was conducted to identify the association between patient demographics and total costs. All analyses were done using SAS 9.4 statistical software (SAS Institute, Inc).

RESULTS

Multivariate analysis showed that sex (P < 0.001), hospital setting (P < 0.001), race/ethnicity (P < 0.01), patient region (P < 0.01), Elixhauser Comorbidity Index score (P < 0.001), presence of metastasis (P < 0.01), total number of procedures (P < 0.001), and length of stay (P < 0.001) were correlated with the cost of treatment of invasive cutaneous melanoma. After stratification, the association between cost and race/ethnicity disappeared for inpatients but remained for Black patients in the outpatient setting (P < 0.001). The association between cost and patient residence regions also differed when the cohort was stratified.

CONCLUSIONS

Strategies addressing disparities in treatment cost of invasive melanoma should differ, depending on the hospital setting where the patient is being treated.

Factors associated with the use of adjuvant radiation therapy in stage III melanoma

Objective

The role of radiation therapy (RT) in melanoma has historically been limited to palliative care, with surgery as the primary treatment modality. However, adjuvant RT can be a powerful tool in certain cases and its application in melanoma has been increasingly explored in recent years. The aim of this study is to explore national patterns of care and associations surrounding the use of adjuvant RT for stage III melanoma.

Methods

The National Cancer Data Base (NCDB) was used to identify patients who were diagnosed with stage III melanoma between 2004 and 2014. Exclusion criteria included those with distant metastatic disease, in-situ histology, no confirmed positive nodes, palliative intent therapy, and dosing regimens inconsistent with National Comprehensive Cancer Network (NCCN) guidelines for adjuvant RT in melanoma. Patients treated with and without adjuvant RT were compared and factors associated with use of adjuvant RT were identified using multivariable logistic regression analyses.

Results

A total of 7,758 cases of stage III melanoma were analyzed, of which 11.7% received adjuvant RT. The mean age of the overall cohort was 58.5 years, and the majority of patients were male (64.7%), white (96.6%), on private insurance (51.3%), and presented to a non-high-volume facility (90.3%). Multivariable regression analyses revealed that patients who present to the hospital in 2009-2014 as compared to 2004-2008 (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.36-1.92), had 4 or more positive nodes (OR 4.30, 95% CI 3.67-5.04), and had microscopic residual tumor (OR 2.11, 95% CI 1.46-3.04) were more likely to receive adjuvant RT. Factors that were negatively associated with receiving adjuvant RT included female gender (OR 0.72, 95% CI 0.61-0.85) and median income of at least $63,000 (OR 0.66, 95% CI 0.52-0.83).

Conclusions

This study demonstrates the rising use of RT for stage III melanoma in recent years and identifies demographic, social, clinical, and hospital-specific factors associated with patients receiving adjuvant RT. Further investigation is needed to explore disease benefits to improve guidance on the utilization of RT in melanoma.

Racial/Ethnic Health Disparities in Dermatology in the United States Part 2: Disease-specific Epidemiology, Characteristics, Management, and Outcomes

Racial and ethnic disparities in dermatology negatively affect outcomes such as mortality and quality of life. Dermatologists and dermatologic surgeons should be familiar with disease-specific inequities that may influence their practice. The second article in this two-part continuing medical education series highlights gaps in frequency, clinical presentation, management, and outcomes by race and ethnicity. We review cutaneous malignancies including basal cell carcinoma, squamous cell carcinoma, melanoma, Merkel cell carcinoma, dermatofibrosarcoma protuberans, and cutaneous T cell lymphoma, and inflammatory disorders including atopic dermatitis, psoriasis, hidradenitis suppurativa, acne vulgaris, and rosacea.

Increasing Access to Specialized Dermatology Care: A Retrospective Study Investigating Clinical Operation and Impact of a University-Affiliated Free Clinic

Introduction

Our objective was to study the impact and clinical operation of an integrated model for free specialized dermatology care via collaboration between an academic institution and a nonprofit outpatient clinic through an analysis of patient demographics and care provided.

Methods

Hope@UMHS is a partnership between the University of Michigan Health System (UMHS) and Hope Clinic (HC) which provides free specialty consultations to uninsured residents of Southeast Michigan. A retrospective chart review was completed for patients referred to the UMHS Dermatology clinic as part of the HOPE@UMHS collaboration from April 2012 through February 2020.

Results

Of the 294 referred patients, 264 were managed in 30 clinic sessions over 8 years, staffed by 92 unique volunteers. Patients most commonly presented with atopic dermatitis (10.5%), seborrheic dermatitis (7.9%), and actinic keratosis (7.4%). The majority of patients (68.2%) were prescribed at least one new medication. Nine skin cancers, including one melanoma, were diagnosed and treated. There were 102 procedures performed. Eighty-seven percent of patients received conclusive evaluation and treatment at the time of their consultation.

Conclusion

Our experience illustrates that providing free, comprehensive dermatology care in a university hospital by partnering with a nonprofit clinic is both feasible and beneficial to the greater community.

Racial and Socioeconomic Disparities in the Delivery of Immunotherapy for Metastatic Melanoma in the United States

Immunotherapy for metastatic melanoma has rapidly expanded, but racial and/or socioeconomic factors often impact the type of therapies delivered for cancer care. This study addressed a crucial public health priority by evaluating disparities in administration of immunotherapy for metastatic melanoma. The National Cancer Database was queried for newly diagnosed metastatic melanoma. Patients were dichotomized based on receipt of immunotherapy based on National Cancer Database coding. Multivariable logistic regression ascertained factors associated with immunotherapy delivery. Subgroup analysis evaluated the interaction between race, insurance status, and income. Secondarily, Cox multivariate and propensity-matched Kaplan-Meier analyses assessed overall survival based on immunotherapy receipt. Of 15,941 patients meeting the selection criteria, 2448 (15.4%) received immunotherapy, and 13,493 (84.6%) did not. Temporal trends showed that utilization of immunotherapy was 8%-12% of patients between 2004 and 2010, with utilization increasing to 29.7% of patients in 2014. Immunotherapy was more likely administered to younger and healthier patients, at academic centers, and in the absence of chemotherapy and brain metastases (P<0.05 for all). African Americans, along with patients with Medicaid and lower incomes were less likely to receive immunotherapy (P<0.05 for all). As expected, immunotherapy was associated with improved overall survival (median 16.3 vs. 8.3 mo, P<0.001). Although immunotherapy for metastatic melanoma is markedly escalating, not all populations experience this rise equally. Because immunotherapy utilization is expected to amplify even further in the future, these public health and economic issues are essential to identify and address appropriately, and have implications on public health policy, pharmaceutical and insurance companies, and value-based oncology. Methods to address these inequalities are also discussed.

Racial differences in time to treatment for melanoma

Background

Longer time from diagnosis to definitive surgery (TTDS) is associated with increased melanoma-specific mortality. Although black patients present with later-stage melanoma and have worse survival than non-Hispanic white patients, the association between race and TTDS is unknown.

Objective

To investigate racial differences in time to melanoma treatment.

Methods

Retrospective review of the National Cancer Database (2004-2015). Multivariable logistic regression was used to evaluate the association of race with TTDS, controlling for sociodemographic/disease characteristics.

Results

Of the 233,982 patients with melanoma identified, 1221 (0.52%) were black. Black patients had longer TTDS for stage I to III melanoma (P < .001) and time to immunotherapy (P = .01), but not for TTDS for stage IV melanoma or time to chemotherapy (P > .05 for both). When sociodemographic characteristics were controlled for, black patients had over twice the odds of having a TTDS between 41 and 60 days, over 3 times the odds of having a TTDS between 61 and 90 days, and over 5 times the odds of having a TTDS over 90 days. Racial differences in TTDS persisted within each insurance type. Patients with Medicaid had the longest TTDS (mean, 60.4 days), and those with private insurance had the shortest TTDS (mean, 44.6 days; P < .001 for both).

Conclusions

Targeted approaches to improve TTDS for black patients are integral in reducing racial disparities in melanoma outcomes.

Improved patient access and outcomes with the integration of an eConsult program (teledermatology) within a large academic medical center

BACKGROUND

Insurance, racial, and socioeconomic health disparities continue to pose significant challenges for access to dermatologic care. Studies applying teledermatology to increase access to underinsured individuals and ethnic minorities are limited.

OBJECTIVE

To determine how the implementation of a teledermatology program affects access to health care and patient outcomes.

METHODS

A cross-sectional evaluation was performed of all ambulatory dermatology referrals and electronic dermatology consultations (eConsults) at Ohio State University within a 25-month period.

RESULTS

Compared with ambulatory referrals, eConsults served more nonwhite patients (612 of 1698 [36.0%] vs 4040 of 16,073 [25.1%]; P < .001) and more Medicaid enrollees (459 of 1698 patients [27.0%] vs 3266 of 16,073 [20.3%]; P < .001). In addition, ambulatory referral patients were significantly less likely to attend their scheduled appointment compared with eConsult patients, as either "no-shows" (246 of 2526 [9.7%] vs 3 of 62 [4.8%]) or cancellations (742 of 2526 [29.4%] vs 8 of 62 [12.9%]; P = .003). There were fewer median days to extirpation for eConsult patients compared with ambulatory referral patients (interquartile range; 80.7 ± 79.8 vs 116.9 ± 86.6 days; P = .004).

CONCLUSION

Integrating dermatologic care through a telemedicine system can result in improved access for underserved patients through improved efficiency outcomes.

Association of Demographic and Socioeconomic Characteristics With Differences in Use of Outpatient Dermatology Services in the United States

Importance

Knowledge regarding differences in dermatologic care for patients with a broad range of dermatologic conditions is limited.

Objective

To elucidate nationwide differences in use of outpatient dermatologic care.

Design, Setting, and Participants

Retrospective analysis of nationally representative data from the 2007 to 2015 Medical Expenditure Panel Survey (MEPS) provided by the Agency for Healthcare Research and Quality. Health care use outcomes for dermatologic conditions (skin cancers, infections, dermatologic inflammatory conditions/ulcers, and other skin disorders) were examined via multivariable logistic regression analyses of outpatient and office-based dermatologist visit rates accounting for sex, age, race/ethnicity, educational level, income, insurance status, region, self-reported condition, and self-reported health status. Participants were 183 054 MEPS respondents who visited a dermatologist from 2007 to 2015.

Main Outcomes and Measures

The primary outcome measure was whether the patient received outpatient care for any dermatologic condition (by payment). The secondary outcomes were annual health care use by individuals with dermatologic conditions (including per capita expenditure for the visit).

Results

Of 183 054 MEPS respondents (mean [SD] age, 34 [23] years; 52.1% female), 19 561 (10.7%) self-reported a dermatologic condition; 9645 patients had a total of 11 761 outpatient visits to dermatologists. Hispanic (adjusted odds ratio [aOR], 0.55; 95% CI, 0.49-0.61) and black (aOR, 0.42; 95% CI, 0.38-0.46) patients were both less likely to receive outpatient care for their dermatologic condition relative to non-Hispanic white patients. Male patients were less likely to receive outpatient dermatologic care than female patients (aOR, 0.66; 95% CI, 0.62-0.70), and Midwestern patients were less likely to receive outpatient dermatologic care than Northeastern patients (aOR, 0.80; 95% CI, 0.70-0.91). Patients with Medicaid or Medicare coverage (aOR, 0.75; 95% CI, 0.68-0.83) and uninsured patients (aOR, 0.39; 95% CI, 0.33-0.47) were both less likely to receive outpatient dermatologic care than privately insured patients. Increasing educational level and income were associated with increased odds of receiving outpatient care for the dermatologic condition.

Conclusions and Relevance

These findings highlight wide-ranging differences in use of dermatologic care in the United States across various demographic and socioeconomic lines. Results of this study suggest an urgent need to further characterize potential dermatologic health care differences and improve use of outpatient dermatologic care among disadvantaged populations.

Characteristics of Patients Hospitalized for Cutaneous Squamous Cell Carcinoma

BACKGROUND

Knowledge regarding the inpatient burden of cutaneous squamous cell carcinoma (cSCC) is limited.

OBJECTIVE

To provide nationally representative estimates for hospitalization characteristics due to cSCC and determine predictors for increased length of stay (LOS) and cost of care.

METHODS/MATERIALS

A retrospective cohort study of the 2009 to 2015 National Inpatient Sample. Weighted multivariate logistic/linear regression models were created to evaluate sociodemographic factors associated with cSCC hospitalization and to assess characteristics associated with cost of care and LOS.

RESULTS

This study included 15,784 cSCC and 255,244,626 non-SCC inpatients (prevalence = 6.2/100,000 inpatients). On average, cSCC hospitalizations lasted 5.8 days and cost $66,841.00. Cutaneous squamous cell carcinoma most often occurred on the scalp (30.57%), face (21.08%), and lower limb (11.93%). Controlling for all other factors, cSCC inpatients presented to larger/urban/teaching hospitals and were most often older non-Hispanic white women. More chronic conditions/diagnoses/procedures and nonwhite race were associated with greater cost of care and LOS. Cost of care and LOS significantly differed between cSCCs of different anatomical sites. The most common procedures performed were skin grafts (27.96%), excisions (25.83%), and lymph node biopsies (11.39%).

CONCLUSION

This study highlights the substantial burden of inpatient cSCC in the United States. Further research is necessary to prevent cSCC hospitalizations and improve inpatient dermatologic care for cSCC.

Racial disparities, cancer and response to oxidative stress

At the intersection of genetics, biochemistry and behavioral sciences, there is a largely untapped opportunity to consider how ethnic and racial disparities contribute to individual sensitivity to reactive oxygen species and how these might influence susceptibility to various cancers and/or response to classical cancer treatment regimens that pervasively result in the formation of such chemical species. This chapter begins to explore these connections and builds a platform from which to consider how the disciplines can be strengthened further.

What's New in Melanoma

Melanoma is rapidly evolving because of advances in noninvasive diagnosis, targeted therapies, and improved prognostic methods. This article discusses what is new in melanoma risk factors, prevention, clinical management, and targeted treatment. The incidence continues to increase worldwide, whereas mortality is steadily improving. This trend reinforces the importance of dermatologists comprehensively understanding all aspects of melanoma. Further research is needed to continue making a material impact on outcomes for patients.