Association Between Area-Level Socioeconomic Disadvantage and Immunotherapy in Patients With Non-Small Cell Lung Cancer

Background

Recent advances in immunotherapy have improved the survival of patients with non-small cell lung cancer (NSCLC). However, data on the association between patient socioeconomic status (SES) and the use of immunotherapy remain scarce. We examined the association between area-level SES and immunotherapy use in patients with stage IV NSCLC in Japan.

Methods

Data from a national inpatient database were used for this analysis. Patients aged ≥ 18 years, hospitalized for stage IV NSCLC, and treated with immunotherapy alone, immunotherapy combined with platinum-based chemotherapy, and platinum-based chemotherapy alone as first-line pharmacotherapy from April 2016 to March 2022 were analyzed. Area-level SES was measured using the area deprivation index and categorized into quartiles. The primary outcome was the use of immunotherapy as a first-line treatment. A multivariate linear regression model was used, adjusted for patient characteristics, years, and hospital fixed effects.

Results

A total of 47,291 eligible patients from 843 hospitals, with 22,205 (47%) receiving immunotherapy. Adjusted analyses showed that patients in the most disadvantaged area were less likely to receive immunotherapy compared with those in the least disadvantaged area (adjusted difference, −2.0 percentage points [pp]; 95% confidence interval, −3.6 to −0.5 pp; p = 0.01). Although not significant, this trend persisted when stratified by urban and cancer-designated hospitals. However, this difference was no longer significant after adjusting for hospital fixed effects.

Conclusion

In Japan, with universal public health insurance with low out-of-pocket costs, living in a socioeconomically disadvantaged area is associated with lower rates of immunotherapy use among patients with stage IV NSCLC. These disparities disappeared within the same hospitals using hospital fixed effects; however, such disparities tended to persist in urban, non-academic, and cancer-designated hospitals. These findings suggest the need for interventions to address the structural barriers, including those within the hospitals, to optimize NSCLC treatment and reduce health disparities.