Survival Outcomes in Stage III to IV Melanoma Before and After the Immunotherapy Era: Persistent Racial and Socioeconomic Disparities.

Abstract

Immune checkpoint inhibitors have transformed the treatment of advanced melanoma, but whether real-world survival improvements have been equitable across demographic and socioeconomic subgroups remains unclear. Using the National Cancer Database, we identified patients diagnosed with stage III to IV cutaneous melanoma from 2006 to 2011 (preimmunotherapy era) and 2015 to 2020 (immunotherapy era). Kaplan-Meier and multivariable Cox models assessed overall survival (OS) and associations with clinical and sociodemographic variables. Among 77,495 patients (64% male, 95% non-Hispanic White), survival improved markedly in the immunotherapy era. For stage III melanoma, the median OS increased from 83.4 months to not reached; the 5-year OS rose from 55% to 67%. For stage IV disease, the median OS doubled from 8.3 to 15.2 months and the 5-year OS rose from 14% to 31%. Despite these gains, disparities persisted. Five-year OS was higher in females than males (60% <i>v</i> 52%), privately insured versus Medicare/uninsured patients (68% <i>v</i> 43%-52%), and those treated at academic versus nonacademic centers (58% <i>v</i> 48%). Survival declined with age (72% in patients younger than 50 years <i>v</i> 33% in those 75 years and older) and was lowest among those in the lowest income or education quartiles. Among racial groups, Black patients had the poorest 5-year OS (37% <i>v</i> 55% in White patients) although limited sample size restricts interpretation. In stage IV disease, the site of metastasis influenced prognosis: patients with liver or brain involvement had the shortest survival, whereas those with lung-only or soft tissue metastases fared better. Although survival has improved in the immunotherapy era, inequities by age, race, sex, insurance, and treatment setting persist. Addressing barriers to timely diagnosis, specialized care, and immunotherapy access remains critical for achieving equitable outcomes in melanoma.