It’s no secret that the outcomes of cancer treatment and the long-term health of cancer survivors vary greatly from one person to the next. Several of the reasons for this variance are well known: age and health status at diagnosis, stage of cancer, choice of treatment, and geographic location. Studies show that we can add another reason to the list—health insurance status.
Take some recent examples. Dasenbrock and colleagues analyzed data from the Nationwide Inpatient Sample from 2005 to 2008 to investigate outcomes of surgery for spinal metastases. After adjusting for demographic, clinical, and place-of-care variables, the investigators found that, compared with privately-insured patients (3.8%), the in-hospital death rate was 6.5% for Medicaid recipients and 7.7% for uninsured patients.
Moreland and colleagues investigated the factors that determine whether breast cancer patients receive mastectomy or breast-conserving surgery with radiation, two treatment strategies with similar outcomes but radically different effects on quality of life. Examining patient records from a single cancer treatment center showed that women with private insurance were almost four times more likely than uninsured women to receive breast-conserving surgery.
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When Fedewa and colleagues analyzed data from the National Cancer Database on survival after diagnosis of uterine cancer, they found that insurance status predicted survival: 89%, 81%, and 76% of privately-insured, uninsured, and Medicaid-insured patients, respectively, were alive after 4 years.
In all three of these studies, a single factor had an outsized impact on outcomes: patients without insurance or with publicly-funded insurance presented with later-stage cancer or were more acutely ill. In the Dasenbrock et al study, uninsured or Medicaid-insured patients were more likely to have nonelective admission, myelopathy, and visceral metastases. In the Moreland et al study, uninsured patients were more likely to have later-stage disease, larger tumor size, and a greater number of lymph node metastases. In the Fedewa et al study, uninsured and Medicaid-insured patients were less likely to present with stage I disease. In all likelihood, patients without private insurance had more limited access to regular health care that might have detected treatable illness at an earlier stage.
Acuity at presentation was addressed directly by Kuzmiak and colleagues, who calculated the tumor stage for 617 insured and uninsured women treated for breast cancer at a single facility between 2002 and 2004. They found that uninsured patients were 66% more likely to present with advanced-stage cancer and large tumor size than insured patients. Uninsured patients were almost twice as likely as insured patients to present with stage III or IV cancer (43.3% vs 23.2%). Whereas only 2% of insured patients had a tumor graded T3, 41.5% of uninsured patients had a tumor of that size.
The overall health of cancer survivors is also affected by cost issues. Tai and colleagues examined the self-reported health status of 4,054 survivors of adolescent or young-adult cancer (ie, cancer diagnosed between ages 15 and 29 years) and 345,592 persons with no history of cancer. They found that 24% of cancer survivors, compared with 15% of other respondents, reported not receiving medical care because of cost. Cancer survivors were significantly more likely to report current smoking, obesity, cardiovascular disease, hypertension, asthma, disability, poor mental health, and poor physical health.
Similar results were reported by Kirchhoff and colleagues, who found that 5-year survivors of adolescent/young adult cancer regularly forgo medical care because of cost. Although similar proportions of survivors and controls had health insurance, 76% of uninsured survivors vs. 48% of uninsured controls and 21% of insured survivors vs. 11% of insured controls were more likely to go without care because of cost. Cost was a particularly strong barrier for survivors aged 20 to 29 years and for women.
Thus, one of our most effective weapons in the fight against cancer isn’t a drug or surgical technique—it’s a good insurance policy.
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