ASO Author Reflections: Uninsurance is associated with worse outcomes following resection for gastro-entero-pancreatic neuroendocrine tumors

PAST

Previous studies have demonstrated that patients in the United States (US) who lack private or government-based health insurance who suffer from a variety of malignancies have shortened survival compared to their insured counterparts^1,2 Additionally, low-income patients in the US with breast and colon cancers have worse survival outcomes than low-income patients who reside in countries with universal healthcare³. Despite the implementation of the Affordable Care Act in 2010, twenty-eight million Americans remain uninsured and struggle to access medical care.

Gastro-entero-pancreatic neuroendocrine tumors (GEP-NETs) are generally indolent with a favorable prognosis, and patients frequently undergo multiple operative and non-operative interventions that have the potential to dramatically alter their clinical course. Until now, how insurance status impacts survival following GEP-NET resection remained unexplored.

PRESENT

In this retrospective study of the multi-institutional US-Neuroendocrine Tumor Study group database, all adult patients aged 18–64 who underwent resection for GEP-NETs were examined⁴. Patients 65 years and older were excluded as these patients are almost exclusively covered by Medicare. Insured (including government and privately-insured patients) and uninsured patients were largely similar in demographic and pathologic variables including TNM stage and tumor grade, however uninsured patients were more likely to have their index resection occur under urgent or emergent scenarios (8 vs 3%, p=0.01). Uninsured patients also had shorter median follow-up time (27 vs 36 months, p=0.06), and while rates of adjuvant and neoadjuvant chemotherapy were similar between groups, uninsured patients were significantly less likely to received post-operative somatostatin analogue therapy (2 vs 10%, p=0.03). Government and privately insured patients had highly similar 1-, 5-, and 10-year overall survival (96, 88, and 74%, respectively) and both of these groups survived significantly longer than patients without insurance (88, 72, and 44%, respectively, p<0.01). On multivariate analysis controlling for TNM stage, tumor grade, ASA class, and patient income designation by zip code, being uninsured was independently associated with a significantly shortened overall survival following index resection for GEP-NETs (Hazard Ratio 2.7, 95% confidence interval 1.3–5.5, p<0.01).

FUTURE

In the US, twenty-eight million people remain uninsured and, as a result, struggle to obtain equal access to care in many areas of medicine. This study demonstrates that, in yet one more malignant disease, uninsurance is a significant risk factor for worse survival outcomes. Continued investigation into disparities impacting patient outcomes is critical for two main reasons. First, highlighting disparities in care frequently and forcefully will continue to draw attention to the untenable state of the US healthcare system. Second, these investigations allow us to identify mediating factors that could be addressed on the provider and hospital level to minimize inequalities within the current healthcare landscape. For example, our study suggests that uninsured patients may not receive equivalent post-operative surveillance or somatostatin analogue therapy, suggesting that targeted financial assistance efforts could focus on these elements of post-operative care to minimize survival disparities for uninsured GEP-NET patients. It is imperative that, while we await meaningful improvement to our healthcare delivery system, we continue to examine, quantify, and expose these disparities.