Veterans Affairs Insurance Disparities for Metastatic Lung Cancer in the Hawaiian Islands

Our plain-English summary of Veterans Affairs Insurance Disparities for Metastatic Lung Cancer in the Hawaiian Islands, by J.Q. Lin, S.Q. Li, T.A. Pezzi, et al (JTO Clinical and Research Reports, 2020).

The study

• Authors: J.Q. Lin, S.Q. Li, T.A. Pezzi, A.S.R. Mohamed, C.D. Fuller, A.B. Chen, B.D. Minsky, D.L. Schwartz, B.Y. Hernandez, S.G. Chun
• Journal: JTO Clinical and Research Reports
• Published: 2020;1(1):100003
• Cited by: 3 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Introduction: The highest concentration of military personnel in the United States is located in Hawaii where occupational exposures, such as to asbestos in the Pacific Fleet shipyards, predispose them to thoracic malignancies. For this reason, Veterans Affairs (VA) insurance outcomes for lung cancer in Hawaii are of interest.

Methods: All cases of lung cancer in the Hawaii Tumor Registry from 2000 to 2015 were evaluated. The selection criterion included evidence of extensive-stage SCLC (ES-SCLC) or metastatic NSCLC. Overall survival was compared using the Kaplan-Meier log-rank method. Univariate analysis and multivariable analysis (MVA) were carried out to understand the variables associated with overall survival.

Results: There were 434 cases of ES-SCLC and 2139 cases of metastatic NSCLC identified. VA insurance (median survival [MS], 2 mo), Medicaid (MS, 4 mo), and Medicare (MS, 4 mo) had worse survival (log-rank p < 0.001) than private insurance (MS, 8 mo). In ES-SCLC, VA insurance (hazard ratio [HR], 2.74; 95% confidence interval [CI]: 1.50-5.01; p = 0.001) and Medicaid (HR, 1.46; 95% CI: 1.04-2.03; p = 0.027) had significantly worse survival compared with private insurance on MVA. VA insurance (HR, 1.84; 95% CI: 1.34-2.53; p < 0.001) and Medicaid (HR, 1.40; 95% CI: 1.20-1.63; p < 0.001) also had worse survival compared with private insurance in metastatic NSCLC on MVA.

Conclusions: VA insurance coverage was associated with dismal survival for metastatic lung cancer that was effectively similar to hospice or supportive care, compelling further investigation to identify reasons for this disparity.

© 2020 The Authors.

In plain English

The authors compared survival by insurance type for metastatic lung cancer diagnosed from 2000 to 2015 in the Hawaii Tumor Registry. Of 434 people with extensive-stage small cell and 2139 with metastatic non-small cell lung cancer, only 62 had Veterans Affairs (VA) insurance. The authors cited Pearl Harbor shipyard asbestos exposure as background but did not measure it. Across both types, median survival was 2 months with VA insurance, 4 with Medicare or Medicaid, and 8 with private insurance. After adjustment, VA insurance was linked to a higher risk of death than private insurance (hazard ratio 2.74, 95% confidence interval 1.50 to 5.01, in small cell; 1.84, 1.34 to 2.53, in non-small cell), as was Medicaid. Medicare's association with survival was not statistically significant after adjustment. VA-insured patients were less likely than privately insured patients to receive chemotherapy. The authors concluded that VA insurance was associated with very poor survival, similar to hospice or supportive care, and urged investigation of why. They noted the small VA group and missing data on fitness and other illnesses, which could possibly explain the results.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective analysis of cancer registry data (brief report)
• Who was studied: 2573 cases of metastatic lung cancer in the Hawaii Tumor Registry, diagnosed 2000 to 2015: 434 extensive-stage small cell lung cancer (ES-SCLC) and 2139 metastatic non-small cell lung cancer (NSCLC). Primary insurance was private for 832, Medicare for 1341, Medicaid for 338 and VA for 62. Military Tricare was counted as private insurance, and uninsured patients were excluded.
• Exposure: Type of primary insurance at diagnosis (VA, Medicare, Medicaid, compared with private). Asbestos exposure at the Pearl Harbor Pacific Fleet naval shipyards is mentioned only as background. It was not measured in this study.
• Main results:
  • Both cancer types combined: median survival was 2 months with VA insurance, 4 months with Medicare, 4 months with Medicaid and 8 months with private insurance (log-rank p less than 0.001).
  • Both cancer types combined: VA insurance had significantly worse overall survival than either Medicaid or Medicare (log-rank p less than 0.001).
  • ES-SCLC: median survival was 7 months with private insurance, 6 months with Medicare, 4 months with Medicaid and 1 month with VA insurance.
  • ES-SCLC, multivariable analysis compared with private insurance: VA insurance HR 2.74 (95% CI 1.50 to 5.01) and Medicaid HR 1.46 (95% CI 1.04 to 2.03) were linked to worse survival. Medicare had no significant effect (HR 1.09, 95% CI 0.83 to 1.42).
  • Metastatic NSCLC: median survival was 8 months with private insurance, compared with 4 months with Medicare, 3 months with Medicaid and 3 months with VA insurance.
  • Metastatic NSCLC, multivariable analysis compared with private insurance: VA insurance HR 1.84 (95% CI 1.34 to 2.53) and Medicaid HR 1.40 (95% CI 1.20 to 1.63) were linked to worse survival. Medicare was not (HR 1.01, 95% CI 0.89 to 1.15).
  • VA-insured patients were less likely to receive chemotherapy than privately insured patients: OR 0.25 (95% CI 0.08 to 0.78) in ES-SCLC and OR 0.19 (95% CI 0.10 to 0.36) in NSCLC.
• The authors' conclusion: The authors concluded that VA insurance was associated with very poor survival for metastatic lung cancer in Hawaii, effectively similar to hospice or supportive care, and that the reasons need further investigation. They said the Hawaii findings might not apply to the whole VA system.
• Limitations the authors state:
  • The VA-insured group was small.
  • The registry did not record performance status (how fit and active patients were) or comorbidity (other illnesses). The poor outcomes could possibly be entirely explained by these or other factors the registry did not capture.
  • The VA insurance results in Hawaii might not be generalizable to the entire VA system.

Topics

Medical terms in this study, explained in our Lexicon: Lung Cancer, Occupational Exposure, Cancer Registry, Overall Survival, Median Overall Survival, Hazard Ratio, confidence interval, Hospice.

Related studies

• Asbestos removal, health hazards, and the EPA. Council on Scientific Affairs, American Medical Association — (1991)
• CpG island methylation and expression of tumour-associated genes in lung carcinoma — R. Dammann, M. Strunnikova, et al. (2005)
• Epidemiology of mesothelioma on Walcheren Island — J. Stumphius (1971)
• Modeled exposure to tetrachloroethylene-contaminated drinking water and the occurrence of birth defects: a case-control study from Massachusetts and Rhode Island — A. Aschengrau, L.G. Gallagher, et al. (2018)
• Asbestos hazard evaluation in Rhode Island schools — G.A. Faich (1980)
• Anthophyllite asbestos from Staten Island, New York: Longitudinal fiber splitting — M. Germine, J.H. Puffer (2022)

Browse more research in JTO Clinical and Research Reports, or return to medical research.