Date of Award

January 2024

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Michael S. Leapman

Abstract

Introduction: Patients with cancer in the United States face barriers in access to care based on insurance status. The relationship between health insurance status and uveal melanoma care specifically is unknown. Here, we explore both the uveal melanoma landscape and the medical insurance landscape in the United States and how they interact. Ultimately, we investigate the associations between insurance status on uveal melanoma care and survival outcomes in order to identify potential modifiable barriers to high quality care for patients with uveal melanoma in the United States.

Methods: This national cross-sectional study utilized the National Cancer Database to identify patients diagnosed with uveal melanoma from 2004-2017. Variations in patient, facility, and clinical characteristics by insurance status were explored. The relationship between these characteristics, in particular insurance status, and key outcomes, including disease stage at presentation, treatment type, time to treatment, 1-year all-cause survival, and 5-year all-cause survival, were investigated. Univariate analysis, multivariate logistic regression models, and Cox proportional hazards regression models were leveraged to explore these relationships.

Results: Of 7,677 patients, 50.0% of patients were insured by private insurance, 40.7% by Medicare, 3.5% by Medicaid, 3.2% by other government insurance, and 2.6% by no form of insurance. Patients most commonly received brachytherapy as their initial form of treatment (66.0%), followed by enucleation / surgical resection (19.4%) and other forms of treatment (i.e., observation, laser photocoagulation, cryotherapy, external beam radiotherapy) (14.6%). 1-year and 5-year all-cause overall survival of the sample was 97.3% and 77.7%, respectively. Patients with Medicaid insurance (stage IV: Odds Ratio (OR): 1.97, 95% Confidence Interval (CI) 1.23-3.16; p=0.005) and no insurance (stage III: OR: 2.05, 95% CI 1.23-3.43; p=0.006; stage IV: OR: 2.01, 95% CI 1.13-3.57; p=0.017) had higher odds of presenting with late-stage disease. Patients with Medicare (OR: 1.39, 95% CI 1.09-1.77; p=0.008), Medicaid (OR: 2.27, 95% CI 1.60-3.22; p<0.001), and no insurance (OR 2.55, 95% CI 1.67-3.90; p<0.001) had significantly higher odds of undergoing enucleation / surgical resection compared to patients with private insurance. Patients with Medicare (OR: 0.72, 95% CI 0.56-0.92; p=0.008), Medicaid (OR: 0.38, 95% CI 0.27-0.56; p<0.001), and no insurance (OR: 0.42, 95% CI 0.27-0.65; p<0.001) were significantly less likely to receive brachytherapy versus enucleation / surgical resection compared to patients with private insurance. Patients with Medicaid (OR: 0.53, 95% CI 0.30-0.92; p=0.025) and no insurance (OR: 0.13, 95% CI 0.04-0.40; p<0.001) were also significantly less likely to receive other forms of treatment. Receipt of brachytherapy (Hazards Ratio (HR): 0.44, 95% CI 0.37-0.50; p<0.001) and other forms of treatment (HR: 0.64, 95% CI 0.52-0.80; p<0.001) were associated with lower risk of death. Later-stage disease presentation, male sex, older age, higher Charlson comorbidity index, treatment in the Northeast, farther residential distance from treatment facility, and ciliary body tumors were significantly associated with higher risk of death (p<0.05 for all).

Conclusions: Barriers in access to uveal melanoma care likely exist for patients with Medicaid insurance and no insurance, resulting in later-stage disease presentation and more radical treatment approaches for these patients. Future efforts should focus on increasing accessibility to regular eye exams to facilitate early tumor identification, reduce treatment disparities, and improve outcomes for patients with uveal melanoma, regardless of insurance status.

Comments

This thesis is restricted to Yale network users only. This thesis is permanently embargoed from public release.

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