Health Insurance Coverage May Mediate Racial/Ethnic Disparities in Late-Stage Breast Cancer

A retrospective analysis, published in JAMA Oncology, found that there was a large difference in breast cancer stage among racial/ethnic minorities that had insurance and access to care.

Researchers noted that these findings do not indicate that insurance alone will eradicate racial and ethnic disparities in breast cancer, as previous studies have shown that equal insurance coverage and access to care will not fix the problem. 

“Adequate insurance coverage for all patients with cancer is an important consideration and one major systemic change that can be pursued to ameliorate consistent disparities,” the authors wrote. “However, reasons for disparities in breast cancer are multifactorial, with opportunities for research across many disciplines.”

In this cohort of 177,075 women with a diagnosis of stage I to III breast cancer identified through the SEER database, 148,124 were insured and 28,951 were either uninsured or receiving Medicaid. A higher proportion of women who were either receiving Medicaid or who were uninsured received a diagnosis of locally advanced breast cancer (stage III) compared with women with health insurance (20% vs 11%). 

In multivariable models, non-Hispanic black (odds ratio [OR], 1.46; 95% CI, 1.40-1.53), American Indian or Alaskan Native (OR, 1.31; 95% CI, 1.07-1.61) and Hispanic (OR, 1.35; 95% CI, 1.30-1.42) women had increased odds of receiving a diagnosis of locally advanced disease (stage III) compared with non-Hispanic white women. After adjustments for health insurance and other socioeconomic factors, associations between race/ethnicity and risk of locally advanced breast cancer were attenuated among non-Hispanic black (OR, 1.29; 95% CI, 1.23-1.35), American Indian or Alaskan Native (OR 1.11; 95% CI, 0.91-1.35), and Hispanic patients (OR, 1.17; 95% CI, 1.12-1.22). Almost half (45%-47%) of racial differences in the risk of locally advanced disease were mediated by health insurance. 

“The ability to quantify the association that insurance has with breast cancer stage is relevant to potential policy changes regarding insurance and a prioritization of solutions for the increased burden of cancer mortality and morbidity disproportionately placed on racial/ethnic minority populations,” the authors wrote.

Without insurance coverage, the absence of prevention, screening, and access to care, as well as delays in diagnosis, consequentially lead to a more advanced stage of disease presented at diagnosis and therefore worse survival. Additionally, previous studies have shown an association between history of cancer and future risk of unemployment. Risk factors for unemployment include having received chemotherapy and undergoing a mastectomy, both of which are common with later-stage breast cancer. 

“Lack of insurance across the cancer care continuum can negatively influence a patient’s ability to be optimally treated, survive cancer, and live a productive life in survivorship,” the authors wrote.

Moreover, maintaining insurance coverage across the entire continuum of cancer care is equally important according to the researchers. A loss of insurance coverage could compromise completion of care, including adjuvant treatment recommendations, lasting years past the initial breast cancer diagnosis. Health care spending is also significantly associated with late-stage diagnosis, with earlier stage diagnosis of breast cancer not only being beneficial for individual patients and families, but also on society as a whole to decrease costs and equity among all populations. 

The researchers indicated that further studies should continue to examine the direct and indirect costs of inadequate health insurance to patients of all racial/ethnic backgrounds, their families, and society as whole. 

Reference:

Ko NY, Hong S, Winn RA, Calip GS. Association of Insurance Status and Racial Disparities With the Detection of Early-Stage Breast Cancer. JAMA Oncology. doi:10.1001/jamaoncol.2019.5672.