Impact of insurance on survival in patients < 65 with head & neck cancer treated with radiotherapy

Mark P Sittig; Michael Luu; Emi J Yoshida; Kevin Scher; Alain Mita; Stephen L Shiao; Diana J Lu; Jon Mallen-St Clair; Allen S Ho; Zachary S Zumsteg

doi:10.1111/coa.13467

Impact of insurance on survival in patients < 65 with head & neck cancer treated with radiotherapy

Clin Otolaryngol. 2020 Jan;45(1):63-72. doi: 10.1111/coa.13467. Epub 2019 Nov 13.

Authors

Affiliations

¹ Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
² Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
³ Department of Radiation Oncology, University of California, San Francisco, CA, USA.
⁴ Department of Medical Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
⁵ Department of Surgery, Division of Head and Neck Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.

PMID: 31661188
DOI: 10.1111/coa.13467

Abstract

Objectives: The United States has a heterogenous health insurance landscape for patients <65 years. We sought to characterise the impact of primary payer on overall survival (OS) in insured patients younger than 65 with head and neck squamous cell carcinoma (HNSCC) treated with definitive radiotherapy.

Design/study/participants: The National Cancer Database was queried for patients <65 years old diagnosed from 2004 to 2014 undergoing definitive radiotherapy ± chemotherapy for cancers of the nasopharynx, oropharynx, hypopharynx and larynx. Uninsured patients and oropharyngeal cancers without known HPV status were excluded.

Main outcome: Overall survival.

Results: Overall, 27 292 insured patients were identified, including 17 060 (62.5%) with private insurance. Median follow-up was 52.1 months. In multivariable models, patients receiving Medicaid (HR = 1.66, 95% CI 1.57-1.75, P < .001), Medicare (HR = 1.64, 95% CI 1.55-1.73, P < .001) and other government insurance (HR = 1.44, 95% CI 1.29-1., P < .001) had independently increased mortality in comparison to those with private insurance. In propensity score-matched cohorts, 5-year OS was 65.5% vs 50.6% for privately vs government-insured patients, respectively (P < .001). In multivariable subgroup analysis, private insurance was associated with improved survival in all subgroups. However, the magnitude of this effect was most pronounced in patients with HPV-positive oropharyngeal cancer vs non-HPV-related cancer (interaction P < .001), younger patients (interaction P = .001), and those without comorbidity (interaction P < .001).

Conclusions: Patients <65 with HNSCC undergoing definitive radiation with private health insurance have markedly longer survival relative to patients with government-sponsored insurance. This illustrates that increasing access to care may be necessary, but is not sufficient, to mitigate the significant disparities in the US healthcare system.

Keywords: head and neck cancer; insurance; oropharyngeal cancer; outcomes; radiation.

Publication types

Multicenter Study

MeSH terms

Adolescent
Adult
Age Factors
Databases, Factual
Female
Head and Neck Neoplasms / economics*
Head and Neck Neoplasms / radiotherapy
Humans
Insurance, Health / statistics & numerical data*
Male
Middle Aged
Squamous Cell Carcinoma of Head and Neck / economics*
Squamous Cell Carcinoma of Head and Neck / radiotherapy
United States / epidemiology
Young Adult