Not all treatments created equal: Identifying barriers to immunotherapy for melanoma

Key takeaways:

• Immunotherapy is an effective yet very expensive treatment for melanoma.
• Barriers to immunotherapy access include proximity to research centers, socioeconomic status, insurance status and education level.

Immunotherapy is a life-saving treatment for melanoma, but not all individuals have access to this treatment, according to a study.

“Health care disparities prevail across all aspects of cancer and cancer treatment, including melanoma,” Fabiola Ramirez, MSN, of the Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, and colleagues wrote. “These disparities arise from social, economic and environmental factors otherwise known as the social determinants of health.”

While melanoma comprises only 1% of skin cancer cases, it causes the majority of skin cancer deaths. Immunotherapy can significantly increase a patient’s odds of survival; however, it is an expensive treatment that is not always accessible.

In fact, according to Ramirez and colleagues’ study, which analyzed 10 studies reporting on disparities in receipt of immunotherapy, those who lack access to clinical trials, did not attain a higher level of education, fall in lower socioeconomic classes, have skin of color and do not have insurance are most at risk.

“Having access to an academic cancer treatment center has been shown to provide a survival advantage,” the authors wrote.

However, patients with skin of color are often underrepresented in clinical trials and those in rural regions of the U.S. do not have access to academic centers, causing them to experience health disparities.

Poverty, which also disproportionally affects patients with skin of color, is a barrier to immunotherapy with those who have a median household income of more than $63,000 being more likely to receive immunotherapy than those with a lower household income.

Commonly dictated by socioeconomic status, education level has also been linked to treatment disparities with one study finding that residence in an area with the highest quartile of high school graduation was associated with an increased likelihood of receiving immunotherapy. Additionally, individuals with lower education levels may be unaware of the signs and symptoms of melanoma.

“A lack of education regarding the importance of skin self-examinations presents a tremendous barrier to the early detection of melanoma,” the authors wrote. “Furthermore, many existing educational campaigns about melanoma display images of melanoma on white skin with a focus on melanoma subtypes affecting predominantly [white individuals].”

In the U.S., insurance plays a significant role in attaining rapid diagnoses and proper treatments. For those in low-income areas who are uninsured or Medicaid-insured, immunotherapy may be unattainable due to its high cost.

“Although treatment of recurrent and/or metastatic melanoma with immunotherapeutic agents has become the standard of care for some patients, the cost of treatment can reach more than $100,000 per patient annually,” they said. “The high cost of treatment with immunotherapy is a major barrier, especially for those with high deductibles and the uninsured.”

Studies have also found that the majority of patients who receive immunotherapy are white, suggesting that Black patients are less likely to receive immunotherapy. Further, of those Black patients that do receive immunotherapy, many are treated for melanoma subtypes that do not respond well to immunotherapy such as acral and mucosal melanomas.

“Because these are non-UV induced, they lack the high tumor mutational burdens and immunogenicity that are leveraged by ICI therapy,” the authors explained.

Overall, there are many health care inequities that bar certain individuals from immunotherapy treatment, leading the authors to call for change.

“As indications for immunotherapy are now quickly expanding to other cancers beyond melanoma, the impact of this problem will continue to grow without action,” the authors wrote. “Recognizing and addressing the barriers responsible for inequitable access to immunotherapy is crucial.”