ACS studies link patients' insurance status to cancer outcomes

ATLANTA—Previous studies have shown that uninsured adults or those in public programs are less likely to receive preventive cancer care. Two new studies from American Cancer Society (ACS) researchers have found that people who were uninsured or enrolled in Medicaid were more likely to present with late-stage cancer than those with private medical insurance (Cancer July 15, 2007). Both retrospective studies analyzed patient data collected from the National Cancer Database.

Michael T. Halpern, MD, PhD, strategic director of Health Services Research at the ACS, and his colleagues looked at the records of 533,715 patients from 1,457 hospitals across the country diagnosed with invasive breast cancer from 1998 to 2003. The proportion of patients with advanced-stage cancer at diagnosis (stage III-IV) ranged from 0% among privately insured patients to 18% among uninsured patients, and 19% among patients with Medicaid (P < .0001).

Women who were uninsured or enrolled in Medicaid at the time of their diagnosis were 2.4 to 2.5 times more likely to have stage III or IV disease, rather than stage I, compared to women with private health coverage. Black and Hispanic patients also were significantly more likely than white patients to be diagnosed at a more advanced stage (P < .001).

"Our results suggest that uninsured and underinsured women are not receiving optimal screening and/or follow-up," Dr. Halpern said.

Oropharyngeal Cancer

Amy Y. Chen, MD, MPH, of Emory University and ACS Health Services Research, and her coinvestigators conducted what may be the first analysis of how insurance status affects oropharyngeal cancer. The study, which included 40,487 patients, showed that, compared to patients with private insurance, patients with no insurance were the most likely to be diagnosed with advanced disease, the largest tumors, or regional lymph node invasion. They also found that Medicaid patients were at demonstrably higher risk for advanced disease.

Other factors associated with more advanced disease at diagnosis included sex (men were at higher risk), age (younger patients were at higher risk), and treatment facility type (patients who were treated at teaching or research facilities were at higher risk). However, all factors considered, type of health insurance remained the strongest predictor of stage at diagnosis and tumor size.

In both studies, health insurance status strongly predicted disease severity at the time of diagnosis. In order to address this diagnostic variable, which leads to poorer outcomes, the authors recommended increasing access to healthcare and targeting screening programs specifically for the uninsured or underinsured.

Having a 'Medical Home'

In an accompanying editorial, Richard C. Wender, MD, president of the ACS and chair of the Department of Family Medicine at Thomas Jefferson University, commented: "Having a usual primary care clinician, a trusted source of care, also known as a medical home, is a strong predictor of improved preventive care delivery." Dr. Wender added that a primary care medical home plays a vital role in reducing cancer mortality. "Individuals who have a regular source of primary care are both more likely to be up to date with cancer screening and more likely to receive timely follow-up and evaluation for abnormal findings on an initial screen," he said.