P44: Social Determinants of Health Predict Lower Receipt of Systemic Treatment and Worse Survival in Patients with Metastatic Melanoma

Melanoma is more common in high socioeconomic status (SES) population, yet low SES populations present with more advanced disease. We set out to understand the effect of social determinants of health on the receipt of systemic treatment for stage 4 melanoma patients within our regional health system.   


Methods:

For patients with metastatic melanoma at our institution between 2010-2021, we collected information on baseline demographics, SES (based on the Area Deprivation Index [ADI], highest quartile considered ‘low SES’), tumor and medical characteristics, and treatment details. Univariable and multivariable regression analyses were performed to identify predictors of systemic therapy receipt. Cox proportional hazards were used to understand predictors of overall survival.


Results:

182 patients were included in our analysis, of whom 120 (65.9%) received any type of systemic therapy. Median follow up for the entire cohort was 383 days (117-1462). Patients who did not receive systemic treatment were older (73 vs 63.5 years) and more likely of low SES (43.5% vs 26.7%). No systemic therapy was also higher in minority race (58.8% vs 31.5%), non-private insurance (42.2% vs 19.7%), having no history of previous melanoma (43.8% vs 23.3%), and symptomatic presentation (39.8% vs 21.3%) (all p< 0.05). On multivariable analysis, increasing age, higher ECOG score, and non-white race were associated with no systemic treatment. On comprehensive review, reasons for not receiving systemic therapy included: advanced disease necessitating palliative care as determined by the medical oncologist (n=29),  medical comorbidities (n=7: 4 wheelchair bound, 1 psychiatric disease, 1 recent history of colitis, and 1 multiple comorbidities), patient refusal (n=5), not recommended (n=18: 15 due to limited metastatic disease treated by either radiation or surgery, 2 mucosal melanomas, and 1 identified during whipple for pancreatic cancer), and death due to other reasons or unknown (n=3). Multivariable Cox analysis demonstrated worse survival for patients who did not receive systemic therapy (HR= 2.05), low SES (HR= 1.63), no spouse/significant other (HR= 2.00), and higher ECOG score (HR= 1.53 per one value increase).


Conclusions:

This study identifies treatment disparities for metastatic melanoma within our regional health system, and highlights socioeconomic risk factors associated with underuse of standard therapies. These findings will be used to guide regional efforts to improve multidisciplinary care for patients with metastatic melanoma in our system.