People without health insurance and those on Medicaid are more likely to be diagnosed with advanced stages of cancer than their peers with private health insurance, American Cancer Society (ACS) researchers report. The findings, published in 2 studies in the journal Cancer (2007;110:395–402 and 403–411), highlight the dramatic impact insurance status has on people's health and well-being.
“It's a very consistent picture in terms of being uninsured or underinsured having a significant effect on advanced disease—it's not just that it appears in one type of cancer and no place else,” says Michael T. Halpern, MD, PhD, Strategic Director of Health Services at the ACS and coauthor of the 2 reports.
Halpern and colleagues used the National Cancer Data Base (NCDB) to compare stage at diagnosis and insurance status in nearly 534,000 women aged 40 years and older diagnosed with Stage I-IV unilateral breast cancer between 1998 and 2003 and in more than 40,000 men and women diagnosed with oropharyngeal cancer between 1996 and 2003. The team is conducting similar analyses on several other types of cancer, as well. The NCDB is a nationwide hospital-based cancer registry that is sponsored jointly by the ACS and the American College of Surgeons (ACoS). More than 1,400 hospitals submit data to the NCDB, representing approximately 75% of all US cancer cases.
The breast cancer analysis showed that just 8% of women with private insurance had Stage III or IV breast cancer at diagnosis, compared with 18% of uninsured women and 19% of women on Medicaid (both statistically significant at P < 0.0001). Advanced stage disease was also more commonly diagnosed in African American (odds ratio [OR], 1.85) and Hispanic women (OR, 1.36) compared with White women (P < 0.001 for both).
Although smaller-scale studies also have shown more advanced breast cancer diagnoses among uninsured and underinsured women, Halpern says the magnitude of the difference was surprising, particularly for Medicaid coverage.
The oral cancer analysis, the first of its kind, found that patients who were uninsured or on Medicaid were significantly more likely to present with Stage III or IV tumors (P < 0.0001) compared with people with private insurance. They also were more likely to present with larger primary tumors and with large regional lymph node metastases (P < 0.0001 for both). For oral cancer, no significant racial or ethnic disparities in stage were noted.
“Even when you have insurance, there's going to be tremendous variety in terms of deductibles, copayments, and access to care, so even having insurance isn't a guarantee of access to timely and adequate care, and the findings for Medicaid point to this,” Halpern says.
That point is crucial in the ongoing debate about reforming the US health care system, according to an editorial accompanying the studies.
“An exclusive focus on the uninsured, although it may be fundamental, is not sufficient,” writes Richard C. Wender, MD, President of the ACS and Chair of the Department of Family Medicine at Thomas Jefferson University. “Adequacy of coverage and availability of appropriate health care services are equally vital.”
Preventive care like mammography is known from previous research to be a casualty of inadequate insurance. Indeed, a recent study from the National Cancer Institute (Cancer 2007;109:2405–2409) cited lack of insurance and higher copays as possible contributors to the 4% decline in US mammography rates from 2000 to 2005. Halpern says his study supports that hypothesis.
Affordable access to primary care clinicians and preventive services like cancer screening are central to adequate coverage, Wender stresses.
“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,” he writes.