E. A. Boevers1, A. M. Button1, B. McDowell1, C. F. Lynch1, S. Bhatia1, J. J. Mezhir1 1University Of Iowa,Surgical Oncology And Endocrine Surgery,Iowa City, IA, USA
Introduction: Previous population studies have shown that insurance status is a significant predictor of survival time for various cancers. This has not been studied in early stage pancreatic ductal adenocarcinoma (PDA), where due to the short survival times, diagnosis at an early stage offers the best chance of survival. The objective of this study was to determine the impact of insurance status on 1) receipt of multimodality therapy including radiation and surgery and 2) overall survival in patients with early stage PDA.
Methods: Surveillance, Epidemiology and End Results Program data were evaluated for patients diagnosed in the years 2007-2011 with Stages I and II PDA. Data were analyzed in a multivariate logistic regression model to examine variables associated with receiving either radiation or surgery, and for overall survival in patients with resectable PDA.
Results: Patients with Stage I (n = 2,104, 22%), IIA (n = 3,323, 34%), and IIB (n = 4,311, 44%) PDA were evaluated. Most patients (n = 8,231, 85%) were insured, while 1,257 (13%) patients were covered by a Medicaid program and 250 (3%) patients were uninsured. Overall, 32% received radiation therapy and 49% were treated with pancreatectomy. After adjusting for age and stratifying by stage, a significant difference in the modes of treatment received by patients with differing insurance was found. Medicaid patients with Stage I PDA were 47% less likely to receive radiation compared to insured patients (p=0.0002),and insured patients were 4.1 times more likely to receive radiation compared to uninsured patients (p=0.004). A similar pattern was seen in patients with Stage II disease. Medicaid patients with Stages I and II PDA were significantly less likely to undergo pancreatectomy compared to insured patients, and insured patients with Stage II PDA were 2.2 times as likely to receive surgery than uninsured patients (p<0.0001).
Median survival across types of insurance was significantly different (Medicaid=8 months, Insured=11 months, uninsured=12 months, p<0.0001). Multivariate analysis with control for age, gender, race, radiation, and surgery showed the risk of death was 1.24 times greater (95% CI 1.2-1.3, p<0.0001) in Medicaid patients versus insured patients.
Conclusion: Treatment with multimodality therapy, including radiation and pancreatic resection, remain remarkably low in patients with early stage PDA. In this study, insurance status had a measurable influence on the treatment patients received and on overall survival. These data provide initial evidence that certain patients and health care providers may require targeted education and improved access to multidisciplinary care. More inquiry is needed to determine why this is affecting the Medicaid population, and how these disparities can be remedied in patients with this disease.