Disparities in Time to Treatment for Skin Cancer

Discussion

Our analysis highlights the association of socioeconomic and demographic factors in the treatment disparities among different patient populations. Age plays a consistent role, with increasing age observed to be associated with delays in overall treatment. This increase in the mean time interval from diagnosis to treatment in older patients may be due to the increased need for workups and consultations to decide on an appropriate management plan (11). A higher risk of mortality is associated with comorbidity score 3 (HR=2.79, 95%CI=1.46-5.30, p=0.002) and score ≥4 (HR=2.75, 95%CI=1.39-5.44, p=0.004) as demonstrated by Chang et al. (14). As older patients are also more likely to suffer from comorbid conditions, they need to be optimized. This, in turn, elucidates the observed delays in the time taken to initiate treatment and surgical procedures in patients with higher CDC scores in our analysis. Furthermore, Lott et al. arrived at a similar conclusion, emphasizing that individuals with melanoma over the age of 85 with multiple comorbid conditions experienced the most substantial delays in undergoing surgery (15).

In contrast to overall treatment, our results showed that the mean time to surgery and radiation was the shortest in the geriatric population. This could be attributed to their later-stage presentation with high-risk lesions requiring more aggressive therapy. A longer time to surgery is associated with decreased overall survival (11, 12). High-risk skin cancers are most often treated with Mohs surgery, which has a curative rate of up to 99% and 95-99% for basal and squamous cell carcinoma, respectively (16). Patients with higher-risk carcinomas who wish to avoid surgery can also be treated with radiotherapy. It is non-invasive and painless and can be used as the primary treatment modality for older individuals with multiple comorbidities, preventing them from becoming suitable candidates for general anesthesia to achieve fitness (17, 18). The curative rate of radiotherapy depends on the type and morphology of skin cancer. Its five-year cure rate for basal cell carcinoma is reported to be 93%-96% (19).

Our research aligns with existing studies showing female patients to have superior survival compared to males (20). Generally, females visit a doctor more often than men and are more likely to seek attention for any suspicious lesion. Thus, they are more regular with follow-ups than their male counterparts, leading to them receiving the treatment earlier. Notably, the frequency of timely treatment for female patients has shown significant improvement following the implementation of the Affordable Care Act (ACA) in 2010 (21). The ACA aimed to expand insurance coverage for the population and enhance access to medical treatments (21). This positive impact is exemplified by the decline in the frequency of delayed treatments among female patients, as demonstrated by Jayakrishnan et al., who reported a decrease from 48.8% to 46.0% in the delayed treatment group (21). This indicates that policy measures like the ACA can play a crucial role in ensuring more timely healthcare access for female patients.

The overall interval of skin cancer treatment was shorter in the non-Hispanic white population compared to people of color, such as Blacks, Asians, and Native Americans. This discrepancy can be attributed to a constellation of factors, including patient education and awareness, physician attitudes, and healthcare accessibility. Notably, there is a concern that the comparatively lower incidence of skin cancer in people of color might engender a sense of complacency, leading to delayed symptom recognition and subsequent treatment at more advanced stages. This delay could be compounded by the heightened pre-operative requirements associated with advanced stages of the disease (22). In addition, darker-skinned individuals, for example, Blacks, are more likely to develop acral lentiginous melanoma (ALM), a rare form of skin cancer. It typically appears on the palms and soles, as well as under the nail beds. Since these sites are not frequently exposed to UV light of the sun, they may be overlooked on self-physical examinations, leading to belated diagnosis and subsequent treatment (23, 24). Hispanic patients are also less likely to seek medical advice for a complete body examination and any suspicious-looking skin lesions (25). This might contribute to their late diagnosis at an aggressive stage, leading to delays in radiotherapy for skin cancer, as evidenced in our study. This observation aligns with the findings of Sukniam et al., who reported that Hispanic female patients experience the most significant delays in receiving surgical, radiation, and chemotherapy treatments for breast cancer (26).

Furthermore, an essential contributor to delayed diagnosis is unequal healthcare access to people of color and deprivation of competitive treatment modalities suited to them. Clinical trials are usually centered on the majority population, which in the United States primarily caters to the white population in treating melanoma (23). CheckMate-067 and CheckMate-037 trials comprised less than 0.7% African American participants and fewer than 1.1% individuals of Asian origin (27, 28). Only seven African-American melanoma patients were included out of approximately 1,100 cases within the Cancer Genome Atlas cohort (23). Such a significant lack of representation in clinical and translational research restricts the applicability of research outcomes to the broader American population, often ignoring the needs of the non-white population. These factors together increase morbidity and mortality due to skin cancer in this population (29). Thus, there is an urgent need to address the disparities in research and healthcare access for underrepresented populations and to spread awareness about the incidence of skin cancer in people of color, facilitating early recognition and treatment.

Our data reveal that uninsured patients face a significant delay in receiving essential treatment, including definitive surgeries, primarily due to constrained access and elevated costs associated with healthcare services. Financial barriers often deter patients from seeking healthcare. Our findings corroborate existing literature showing that individuals with private health insurance tend to access treatment more promptly than those reliant on government-sponsored insurance such as Medicaid (30-32). High-income and comprehensive health insurance plans are typically associated with timely and appropriate treatment. This connection between income, education, and health underscores that individuals with better education levels and awareness of healthcare importance tend to pursue treatment earlier, leading to improved outcomes (33).

However, our findings contradict this observation, as those with a higher income received delayed treatment and surgery. This discrepancy can be explained by the greater likelihood of them exploring alternative treatment options or seeking out multiple opinions, including waiting for consultations with renowned specialists to make an informed decision, which can delay initiating definitive treatment for skin cancer.

Shorter treatment and surgery time for insured patients correlates with our finding of shorter time to radiation for patients living in urban areas. This correlation is grounded in the fact that individuals in rural areas are more likely to be uninsured with comparatively less access to health care than urban and metropolitan residents (34). Owing to this, cancer mortality rates are higher for patients residing in rural areas (35, 36).

The clinicopathology of cancer plays a crucial role in management decisions and treatment planning. Lesions can often be classified into high and low grades based on the pathology and extent. Lesions classified as high-grade or advanced stages may require more intensive diagnostic workup, aggressive treatment including surgery, and closer monitoring involving a multidisciplinary approach (37). Chemotherapy, immunotherapy, and radiotherapy are often used as adjunct therapies for high-grade or advanced-stage cancer, and they can help to improve treatment outcomes and reduce the risk of recurrence. Thus, patients with high-risk lesions often face delays in initiating their treatment but often receive priority for surgery and chemotherapy due to the aggressive nature of their cancer and the potential for a worse prognosis if left untreated.

Our analysis revealing extended delays for patients within academic centers compared to comprehensive and community centers aligns harmoniously with prior research highlighting the role of racial disparities and treatment facility disparities in the time taken for treatment initiation among patients with non-small cell lung cancer (38). Due to their prominence and specialization, academic medical centers tend to shoulder heavier patient loads and handle a higher frequency of intricate cases. This inevitably results in longer waiting times for appointments with specialized healthcare professionals and the commencement of treatment. Academic centers also often involve a multidisciplinary approach and in-depth diagnostic assessments to address the complexities of the cases they receive. Consequently, considerable time is spent coordinating care among various specialties and making informed decisions paramount to achieving optimal patient outcomes. While this approach ensures the highest quality of care, it can inadvertently lead to extended waiting times for patients before their treatment journeys commence.

Our study sheds light on several underlying factors contributing to treatment disparities among a diverse patient population. However, our results are subject to certain limitations. Our data are derived from the National Cancer Database, a retrospective database that relies on the accuracy and completeness of the information provided by participating institutions. Therefore, there may be a potential for inaccuracies or missing data in the dataset. Additionally, our study does not highlight the relation of overall survival to treatment disparities, nor does it illuminate how these disparities affect the quality of life or long-term outcomes for patients. This necessitates further research to address these gaps in knowledge and provide a comprehensive understanding of the impact of treatment disparities on patient outcomes.