UNDERSTANDING THE RELATIONSHIP BETWEEN INSURANCE TYPE AND TESTICULAR GERM CELL TUMORS STAGE PRESENTATION USING THE NATIONAL CANCER DATABASE (NCDB).

Testicular germ cell tumors (TGCT) are one of the most common malignancies in young to middle-aged men. Though highly treatable at all stages, identifying the disease at an early stage is crucial to maximizing quality-of-life for survivors and minimizing treatment toxicity. In the United States (U.S.), access to healthcare is highly dependent on insurance status and insurance quality. Little is known about the effect of insurance providers and the TGCT disease stage in which patients are diagnosed. Herein, we attempt to investigate the relationship between the insurance provider and the TGCT disease stage. We hypothesize that patients who are uninsured or insured under Medicaid are more likely to present with higher-stage TGCT than patients who are privately insured. Using the National Cancer Database (NCDB) from 2004 to 2016, we captured all men aged 18 years or older diagnosed with TGCT. We calculated a descriptive demographic characteristic for our study cohort. Using multivariable logistic regression analysis, we identified significant predictors for the outcome of late-stage presentation. Late-stage presentation was defined as any TGCT of stage II or stage III. Further, we used a multivariable Multinomial (polytomous) logistic regression modeling to calculate the adjusted probability for TGCT stage presentation for each insurance provider. Finally, we conducted an adjusted risk difference analysis to quantify the statistical significance difference between the adjusted probability for stage presentation. We identified 70,757 individuals with TGCT;;significant predictors of presenting with;late stage TGCT;included having non-seminoma;disease compared to seminoma (OR; 3.08, 95%CI; [2.96,3.2], p <0.01), being uninsured compared to;privately insured;(OR; 1.33, 95%CI; [1.25,1.41], p <0.01), and being on Medicaid compared to private insurance (OR; 2.09, 95%CI; [1.97,2.22], p <0.01). Significant predictors are in;Table 1. Multinomial (polytomous) logistic regression modeling adjusted probability showed that Medicaid patients are less likely to present with early stage disease than;privately;insured.(Adjusted risk difference (ARD) = -0.15 [-0.16,-0.14], p <0.01), Medicaid patients are more likely to present at stage II compared to private insurance (ARD = 0.01 [0.009,0.02], p= 0.01), and Medicaid patients are more likely to present at stage III compared to privatly;insured (ARD = 0.14 [0.12,0.15], p <0.01) (figure 1). Our results support the conclusion that U.S. patients who are uninsured, publicly insured, or have unknown insurance status are significantly more likely to present with higher-stage TGCT than privately insured patients. Further, patients insured under Medicaid appear to have the greatest disparity among all these groups. In many cases, insurance status may directly result in diagnosis delay. However, the cause of this relationship is likely multifactorial and worthy of further examination. Medicaid-insured patients may have coverage for primary care. Still, they may be less likely to receive an early diagnosis due to factors not captured in NCDB, such as lower health literacy, higher rates of low English proficiency, higher rates of discrimination, and greater difficulty scheduling appointments. Reducing these disparities would result in improved quality-of-life, reduced patient costs, and lower mortality. For both individual providers and public health organizations, it is imperative to work to ensure earlier diagnosis for these patients. [ABSTRACT FROM AUTHOR]