Is There an Association Between Insurance Status and Survival and Treatment of Primary Bone and Extremity Soft-tissue Sarcomas? A SEER Database Study

• Published in: Clinical orthopaedics and related research 2020-03, Vol.478 (3), p.527-536
• Main Authors: Smartt, Anne A., Jang, Eugene S., Tyler, Wakenda K.
• Format: Article
• Language: English
• Subjects: Adolescent; Adult; Amputation; Bone cancer; Bone Neoplasms - economics; Bone Neoplasms - mortality; Breast; Databases, Factual; Diagnosis; Epidemiology; Extremities; Female; Head and neck; Health Status Disparities; Healthcare Disparities - economics; Humans; Insurance Coverage - statistics & numerical data; Insurance, Health - statistics & numerical data; Lymph nodes; Lymphoma; Male; Medicaid; Metastases; Metastasis; Middle Aged; Patients; Population studies; Proportional Hazards Models; Retrospective Studies; Sarcoma; Sarcoma - economics; Sarcoma - mortality; SEER Program; Soft Tissue Neoplasms - economics; Soft Tissue Neoplasms - mortality; Surgery; Survival; Survival Rate; Uninsured people; United States; Young Adult
• ISSN: 0009-921X; 1528-1132
• DOI: 10.1097/CORR.0000000000000889

Several recently published population-based studies have highlighted the association between insurance status and survival in patients with various cancers such as breast, head and neck, testicular, and lymphoma [22, 24, 38, 41]. Generally, these studies demonstrate that uninsured patients or those with Medicaid insurance had poorer survival than did those who had non-Medicaid insurance. However, this discrepancy has not been studied in patients with primary bone and extremity soft-tissue sarcomas, a unique oncological population that typically presents late in the disease course and often requires referral and complex treatment at tertiary care centers-issues that health insurance coverage disparities could aggravate. (1) What is the relationship between insurance status and cause-specific mortality? (2) What is the relationship between insurance status and the prevalence of distant metastases? (3) What is the relationship between insurance status and the proportion of limb salvage surgery versus amputation? The Surveillance, Epidemiology, and End Results database (SEER) was used to identify a total of 12,008 patients: 4257 patients with primary bone sarcomas and 7751 patients with extremity soft-tissue sarcomas, who were diagnosed and treated between 2007 and 2014. Patients were categorized into one of three insurance groups: insured with non-Medicaid insurance, insured with Medicaid, and uninsured. Patients without information available regarding insurance status were excluded (2.7% [113 patients] with primary bone sarcomas and 3.1% [243 patients] with extremity soft-tissue sarcomas.) The association between insurance status and survival was assessed using a Cox proportional hazards regression analysis adjusted for patient age, sex, race, ethnicity, extent of disease (lymph node and metastatic involvement), tumor grade, tumor size, histology, and primary tumor site. Patients with primary bone sarcomas with Medicaid insurance had reduced disease-specific survival than did patients with non-Medicaid insurance (hazard ratio 1.3 [95% confidence interval 1.1 to 1.6]; p = 0.003). Patients with extremity soft-tissue sarcomas with Medicaid insurance also had reduced disease-specific survival compared with those with non-Medicaid insurance (HR 1.2 [95% CI 1.0 to 1.5]; p = 0.019). Patients with primary bone sarcomas (relative risk 1.8 [95% CI 1.3 to 2.4]; p < 0.001) and extremity soft-tissue sarcomas (RR 2.4 [95% CI 1.9 to 3.1]; p < 0.001) who had Medicaid insura