Investigating Treatment Contraindication Based On Comorbidity Status In Patients Diagnosed With Melanoma In The United States
Daniel Boczar, MD1, Maria T. Huayllani, MD1, Gabriela Cinotto, MD1, Aaron C. Spaulding, PhD1, Sanjay Bagaria, MD1, Brian D. Rinker, MD1, Oscar J. Manrique, MD2, Antonio J. Forte, MD. PhD1.
1Mayo Clinic, Jacksonville, FL, USA, 2Mayo Clinic, Rochester, MN, USA.
PURPOSE: While the majority of patients diagnosed with melanoma tend to be good candidates for pursuing necessary treatment, there remain some who are refused curative measures based upon comorbidities. We hypothesized that some patients may not receive the treatment they need based upon modifiable factors. This studys aim was to analyze the main reasons for patients to be denied treatment for malignant melanoma, and unveil relative disparities in the untreated group of patients in the United States.
METHODS: National Cancer Database (NCDB) was used to select patients with melanoma from 2004 to 2015. We excluded patients who did not receive treatment by reasons other than contraindication because of comorbidity and patients with unknown information about the treatment. We categorized patients in 2 groups [1-Received treatment (RT); 2-Treatment contraindicated because of comorbidity (TCBC)]. Chi-Square and Mann-Whitney test were used to estimate statistical significance. Moreover, we performed multivariate logistic regression to find independent associations adjusted for confounders.
RESULTS: A total of 499,092 patients met the criteria of the study. Among them, 525 had treatment contraindicated because of comorbidity (0.1%) and 498,567 who received treatment (99.9%). Patients with TCBC, had a mean age superior than RTP [69.63 years (SD 15.509) versus 61.37 (SD 16.158)]. Most of the patients with TCBC were male (63.6%), insured by the government (66.1%), invasive tumor (94.9%), Stage IV (60.8%) and with metastasis at diagnosis (53.5%). Interestingly, 71.8% of them had Score 0 on Charlson/Deyo Score of comorbidities. Multivariate logistic regression demonstrated that increase in age and Charles-Deyo Comorbidity Score were independently associated with higher odds of TCBC. However, we also observed higher odds for TCBC in patients with government insurance [OR 1.336 (1.0321.728), P = 0.028] or not insured [OR 2.751 (1.7644.290), P < 0.001] compared to private insurance; Metastasis at diagnosis [OR 4.976 (3.3277.440), P < 0.001]; And Stage III [OR 4.542 (2.7677.457), P < 0.001] or Stage IV [OR 15.268 (8.82226.424), P < 0.001] compared to Stage 0. Moreover, lower odds of TCBC were found in tumors located in trunk [OR 0.590 (0.4180.831), P = 0.003] and extremities [OR 0.453 (0.3240.633), P < 0.001] compared to head and neck.
CONCLUSIONS: This investigation of the NCDB for melanoma treatment revealed a significantly higher likelihood of non-treatment for elderly patients with increased Charles-Deyo Comorbidity Score, patients with government-only or no insurance, evidence of metastasis at diagnosis, and advanced stage of disease. Greater efforts for melanoma treatment equality in the US are indicated.
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