A study of lung cancer biomarkers by type of health insurance

Cary Gross, MD, discusses the results of a retrospective study of patients with advanced non-small cell lung cancer (NSCLC) showing an association between Medicaid insurance, levels of biomarker testing, and patient outcomes.

The study, published in Journal of the National Comprehensive Cancer Network, looked at a sample of 6145 commercially insured and 865 Medicaid beneficiaries with advanced NSCLC. These patients received their diagnosis between January 2011 and September 2019, and data were collected from a US National Institutes of Health database.

What the researchers found was that Medicaid beneficiaries were less likely to have undergone biomarker testing (HR, 0.81; P < 0.001), any first-line treatment (HR, 0.72; P < 0.001) or first-line biomarker-targeted therapy (HR, 0.70; P < 0.001). Moreover, Medicaid beneficiaries were more likely to be black or African American at 20% and 9.3% (P < .001), respectively, also indicating that they were less likely to undergo biomarker testing at 57% vs. 71% (P < 0.001).

These differences affected patient outcomes, as Medicaid beneficiaries who had biomarker testing had a lower risk of death compared with patients without biomarker testing (HR, 1.27; 95% CI, 1, 06–1.52; P = 0.010). However, compared with commercially insured NSCLC patients, there was a higher risk of death for Medicaid beneficiaries (HR, 1.23; P< 0.001), which was only slightly adjusted when considering patient type of testing and treatment (HR, 1.12;P= 0.010).

Gross, founder and director of Yale’s Center for Public Policy and Cancer Outcomes Research, notes that these differences in testing were also seen when looking at individual biomarker tests. For example, 51% of Medicaid beneficiaries had EGFRtesting versus 65% in the commercially insured group and 48% of Medicaid beneficiaries had evidence of ALK testing versus 63%. However, biomarker testing rates were still low in both PD-L1 testing groups—37% in the commercially insured group versus 28% in the Medicaid group and 34% versus 22% in the BRAFtesting,

Gross discusses these differences between beneficiaries with commercial insurance and Medicaid patients, but also highlights how patients in general may not be receiving the levels of biomarker testing they need.


0:07 | In terms of testing, we found that Medicaid patients were significantly less likely to receive biomarker testing. So, for example, in EGFRtesting about 65% of privately insured patients received EGFRtesting against 41% of Medicaid patients. ALKtesting was in 63% of private versus 48% of Medicaid, and this was a consistent finding across all the different biomarkers we looked at. Finally, if you put it all together to ask which patients received all the tests they should have received at any given time, rather than each of the individual biomarkers, we found that 45% of patients with private insurance had received all of the recommended tests. But only 34% of patients who have Medicaid [received all the recommended testing].

1:04 | So there are 2 main findings here. First of all, there is a difference, Medicaid is significantly less than private insurance, but also, even with private insurance, only 45% of patients received the recommended test [at data cutoff]. I think we’re in a situation here where it’s important to look at the inequity, but it’s also important to look at the overall focus of what we’re doing and how we can intervene to improve access to biomarker testing for all patients.

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