Patients With Bone Sarcomas of Lower-Extremity and Non-Private Insurance Linked With Higher Amputation Rates, Worse Outcomes

R. Lor Randall, MD

Amputation is an independent predictor of poor outcomes among patients with high-grade bone sarcoma of lower extremity, and non-private insurance was found to be linked with increased likelihood of amputation and an advanced stage at presentation in this patient population, according to results of a National Cancer Database study that were published in Annals of Surgical Oncology.

In the study, 5781 cases of high-grade bone sarcoma of the lower extremity from 2004 to 2017, and Kaplan-Meier and Cox regression were utilized to determine the impact of amputation on survival.

Results showed that amputation (HR, 1.516; 95% CI, 1.259-1.826; P < .001) and advanced-stage disease (HR, 0.248; 95% CI, 0.176-0.351; P < .001) were both independent predictors of poor overall survival. Moreover, amputation was most likely to be performed among patients who had non-private insurance (HR, 1.736; 95% CI, 1.191-2.531; P = .004), which was found to be mirrored for advanced-stage disease at presentation (HR, 0.611; 95% CI, 0.414-0.902; P = .013)

In an interview with OncLive^®, study author R. Lor Randall, MD, who is the David Linn Endowed Chair for Orthopaedic Surgery and professor and chair of the Department of Orthopaedic Surgery, University of California Davis Health, discussed the analysis and how these outcomes for patients with high-grade bone sarcomas can be improved.

OncLive^®: Please discuss the background to the National Cancer Database study on how non-private health insurance predicts advanced age of presentation amputation and lower extremity in patients with high grade bone sarcoma.

Randall: This is an insightful study in that it shined a light on the fact that patients who are uninsured, or don't have commercial payers, have a higher predilection for amputation for bone sarcomas around the lower extremity, which basically means that they're probably getting access to care later than many other patients. This is a new finding, and it is basically saying that those who don't have the resources and access that many do, or those with third-party payers, are really going to suffer worse outcomes because of that.

Therefore, we need to drill down on how we can better serve the cancer population who have compromised resourcing.

How was this study designed?

We used the National Cancer Database to look at insurance statuses of patients who have lower-extremity bone sarcomas, and looked at their rate of amputation. We found that patients who had non-commercial contracts, such as Medicare, and those who had no insurance, had a higher predilection for amputation. That is not to say that surgeons prefer to do that; we don't do this inferentially. That's not to say that surgeons are choosing to do amputations because of insurance status.

What is more likely happening, but we can't prove, is that [these patients’] tumors are more advanced in their stage, they have a larger tumor that is high grade, and it is not amenable to a limb salvage procedure—because they were unable to get into a provider in a short period of time because of access issues. They may [go to] hospital X, which sees them as underinsured, and then they end up in a safety net facility. Six weeks, or months later, their tumor has progressed, they're no longer a candidate for a limb salvage procedure, and they get an amputation. If they had been seen earlier by some of these non-safety net facilities, they may have been able to get their procedure done sooner.

What can be done as an oncology community to try and alleviate this issue?

State governments, and potentially the federal government, need to look more critically at health care disparities and access. It speaks to national health care systems and all of the toil and angst around health care access to the United States compared with other countries. Now, what's interesting to postulate is that for those countries with national health care systems, many of them still have fast track for having a different insurance plan for those who can afford it. In Canada, for example, there is a route by which you can be seen sooner by going through different channels, because you have a third-party insurance plan as opposed to the national plan.

Is it worth doing a similar study of study in other sarcoma populations or other cancer types?

I would encourage that. These are obviously rare tumors, and we have to go to national registries, but it would be even for cancer centers that have large practices of the big 5 cancers: breast, prostate, lung, colorectal, thyroid, etc. [Researchers could] see how aggressive their surgeries are based upon socioeconomic status, whether or not they had third-party payers, if they had state plans, or they had no insurance to look at, and see how much further along their patients were based upon that stratification.

Is there anything else that you think community oncologists should know about this research?

It raises awareness for the community oncologists to realize, depending upon their own practice setting, that they need to make aware that they may not, for reasons beyond their control, be seeing patients in a timely manner, or patients may be getting compromised care, because they cannot be seen at their setting.

We need to potentially advocate for these issues with peer-reviewed data to try and reconsider policies at their own institutions. Now, that sounds naïve, for sure, because with no money, no mission, and people have bottom lines, they have to work through their systems to be able to keep the lights on. However, we have data here. There are going to be other studies showing this as well—that if you if you don't get access in a timely manner, your outcomes are worse.

Reference

Jaward MU, Pollock BW, Alvarez E, et al. Non-private health insurance predicts advanced stage at presentation and amputation in lower extremity high grade bone sarcoma: a National Cancer Database study. Ann Surg Oncol. Published online March 19, 2022. doi:10.1245/s10434-022-11494-4