Does spending for subspecialty care in advanced-stage melanoma matter: Are greater access costs actually associated with increased use of immune therapy and improved survival among patients with low income?

Abstract

Few studies evaluate the relationship between access costs, patient income, use of immunotherapy, and outcome in advanced-stage melanoma. We queried the National Cancer Database to identify patients undergoing treatment for stage IIIC/D or IV melanoma between 2015 and 2019. Access cost was defined as (distance to treating center) × (regional gas price)/(regional vehicle fuel efficiency) with gas price determined using US Energy Administration reports and fuel efficiency using Kelley Blue Book reports. Patients in the lowest income quartile but highest quintile for access cost were 1:1 propensity-score matched for age, comorbidity and stage to those in the lowest income quartile but lowest quintile for cost. Kaplan-Meier modeling was used to identify factors associated with 5-year overall survival. In total, 1,051 patients had low income as defined by National Cancer Database (<$40,227 annually). The absolute range in access cost was $0 to $990.7. On unadjusted comparison, patients with lowest income quartile but highest quintile for access cost were more likely to have private insurance (30.4% vs 20.8%), undergo treatment at academic centers (59.7% vs 33.2%), receive immunotherapy (58.6% vs 56.4%), and demonstrate better rates of overall survival (46.6% vs 28.1%) than those with lowest income quartile but lowest quintile for cost (all P < .01). On comparison of matched cohorts, overall survival for those with high access cost was better than those of patients with low access cost (percent overall survival, 50.1% vs 29.6%, P < .01). Some patients with low income with advanced-stage melanoma travel for care in academic centers, are more likely to receive immunotherapy and demonstrate improved overall survival. Improved outcomes in this population will rely on efforts to mitigate financial burden and educate patients/providers.