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Immunotherapy For Melanoma In The United States: A National Cancer Database Analysis
Daniel Boczar, MD1, Maria T. Huayllani, MD1, Gabriela Cinotto, MD1, Aaron C. Spaulding, PhD1, Sanjay Bagaria, MD1, Brian D. Rinker, MD1, Oscar Manrique, MD2, Antonio J. Forte, MD. PhD1.
1Mayo Clinic, Jacksonville, FL, USA, 2Mayo Clinic, Rochester, MN, USA.

PURPOSE: Cancer immunotherapy has drastically increased as a treatment option in recent years, including in melanoma management. The goal of this nationwide study was to analyze significant trends in immunotherapy use in malignant melanoma treatment in the United States and to identify relative disparities in these treatment trends.
METHODS: National Cancer Database (NCDB) was used to select patients with melanoma from 2004 to 2015 treated with immunotherapy. Patients whose immunotherapy was recommendation but did not received it (refused, or unknown if it was administered) were excluded. We assessed variables related to characteristics of the patients, hospital, tumor and year of diagnosis. Moreover, a Cox regression model was performed to assess factors that impacted mortality in these patients adjusting for confounders.
RESULTS: A total of 20,072 patients met the criteria of the study. Immunotherapy treatment increased 201,79% from 2004 (n=1281) to 2014 (n=2585). The patient's mean age was 54.24 years (SD 15.466). Most of the patients were male (61,9%), with private insurance (62.8%), living in a metropolitan county (80.9%) in a zip code with a high income (median household income superior to $48,000), high education (percentage of adults without high school diploma below 12.9%) and treated in Academic/Research Programs (44.1%) or Comprehensive Community Cancer Programs (26.2%). Cox regression model for survival analysis showed that age, stage IV, presence of ulceration, and metastasis at diagnosis were independently associated with mortality. Interestingly, analysis demonstrated protective factors: female patients [OR 0.792 (0.7350.854), P < 0.001] compared to male; Private insurance [OR 0.707 (0.6040.829), P < 0.001] compared to not insured; high education [OR 0.834 (0.7280.976), P = 0.023] compared to low education; tumor in extremities [OR 0.809 (0.7340.893), P < 0.001] compared to tumor in head and neck; and Academic/Research Program [OR 0.792 (0.6900.910), P < 0.001] compared to Community Cancer Programs.
CONCLUSION: The overwhelming majority of patients who received immunotherapy for melanoma in the United States from 2004-2015 were of a higher socioeconomic and education level. Patients with significantly better prognosis following treatment were more likely to be female, privately insured, of higher education status, have lesion located in the extremities, and treated at Academic/Research Programs. Identification of these disparities in melanoma immunotherapy patients may help to develop enhanced protocols for utilization of this rapidly evolving treatment option.


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