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Skin melanoma is the 5th most common type of cancer in the United States. Strikingly, 1 in 5 Americans develop skin cancer by the age of 70, and an average of 2 people die from skin cancer each hour. However, if detected while the tumor is still only present at the skin, the 5-year survival rate is 98%. When melanoma is diagnosed later, such as when the cancerous cells have traveled to the lymph nodes or other organs, survival is considerably worse, with 5-year rates of 64% and 23%, respectively.
Therefore, it is extremely important to diagnose skin cancer early. Recent research has begun to explore the factors that make patients more or less likely to have an early diagnosis, with a goal of identifying specific patient groups that need to be extra aware of their skin health. A study by Abudu and colleagues published in November of 2019 investigated the effect of health insurance status on the likelihood of having a late diagnosis of skin melanoma. In this work, the authors pulled data from the National Cancer Database from 177,254 cases of metastatic melanoma that were diagnosed from 2004 to 2015. Late-stage cancer diagnosis was defined as stage III or stage IV disease, which is when the cancer has spread from its primary site to nearby lymph nodes, skin, or to a different organ such as the brain, lungs, liver, or intestines.
Overall, they found that patients with private insurance were more likely to diagnose skin melanoma early compared to patients with Medicaid or no health insurance. Specifically, patients with Medicaid or no health insurance at all were found to have 3.1 or 2.2 greater odds of being diagnosed with late-stage melanoma when compared to patients with private insurance. This analysis was adjusted for common risk factors of late stage diagnosis including age, sex, race/ethnicity, educational attainment, income, comorbidities, and geographic location. These findings agreed with a prior paper by Amini et al. that reported an increased risk of late-stage melanoma for patients with Medicaid or no health insurance, however that paper had a smaller patient sample size and did not control for income, comorbidities, or geographic location.
Importantly, some states allow for patients to enroll in Medicaid after they have received a cancer diagnosis. The data from this paper do not distinguish how many of the patients that were categorized as having “Medicaid” actually had Medicaid before the time of diagnosis versus how many had no insurance at all and retrospectively enrolled after diagnosis.
Assuming the number of patients who retrospectively enroll in Medicaid is small, why would those patients be less likely to receive an early diagnosis? The authors pointed out that only 56% of dermatologists accept Medicaid. Currently, patients with Medicaid and private insurance wait an average of 50 days and 37 days, respectively, to see a dermatologist, potentially also contributing to the increased risk of late-stage melanoma in patients with Medicaid. Further, the authors suggested that only about half of new melanoma cases are included in the National Cancer Database, due to frequent diagnoses outside of hospitals (which may therefore not be entered into the database).
Things that seem harmless can have an enormous impact on your risk of skin melanoma. Incredibly, having a lifetime total of just 5 sunburns gives you double the risk of having skin melanoma, and further sunburns are associated with even greater odds of developing skin cancer. Given the frightening frequency with which Americans are diagnosed with skin melanoma, continued investigation of the factors that lead to earlier diagnosis (and therefore more successful treatment) are of significant interest for public health efforts.
Edited by Aparna Singh
Abudu B., et al. Quantitative associations between health insurance and stage of melanoma at diagnosis among nonelderly adults in the United States. Cancer. 2020 Feb 15;126(4):775-781. doi: 10.1002/cncr.32587.
Photograph used from Pictures of Money, Flickr, without modification.