Insurance Status Linked To Cancer Outcomes

The new findings on stage at diagnosis and survival by insurance status use data from the National Cancer Database (NCDB), a hospital-based registry sponsored by the American College of Surgeons and the American Cancer Society, the only national registry that collects information on patient insurance status.

In 2007, the American Cancer Society launched a nationwide campaign to highlight the role of access to quality care for all Americans. While advances in the prevention, early detection, and treatment of cancer have resulted in an almost 14 percent drop in the death rates from all cancers combined from 1991 to 2004 in the U.S., with remarkable declines in mortality for the top three causes of cancer death in men (lung, colorectal, and prostate cancer) and two of the top three cancers in women, (breast and colorectal cancer), not all segments of the population have benefited equally from this progress.

Evidence suggests that some of these differences are related to lack of access to health care. In particular, the lack of health insurance, or inadequate health insurance, appears to be a critical barrier to receipt of appropriate health care services. The report provides an overview of systems of health insurance in the United States and presents data on the association between health insurance status and screening, stage at diagnosis, and survival for breast and colorectal cancer based on analyses of the National Health Interview Survey (NHIS) and the NCDB. Among the report's findings:

• For all cancer sites combined, patients who were uninsured were 1.6 times as likely to die in five years as those with private insurance.
• The relationship between access to care and cancer outcomes is particularly striking for several cancers which can be prevented or detected earlier by screening and for which there are effective treatments, including breast and colorectal cancer. At every level of education, individuals with health insurance were about twice as likely as those without health insurance to have had mammography or colorectal cancer screening.

For breast cancer, the article reports that:

• Women without health insurance are about half as likely as those with private health insurance to have received a mammogram in the past two years (38.1 percent of uninsured women versus 74.5 percent of insured women age 40-64), a pattern seen for all race/ethnicities studied (white, African American and Hispanic) at all levels of education.
• Twenty to 30 percent of uninsured women were diagnosed with late stage (stage III/IV) breast cancer, compared with ten to 15 percent of privately insured patients.
• Uninsured women were also less likely to be diagnosed with Stage I (early) breast cancer than privately insured women. In white women, where this disparity was greatest, almost 50 percent of those who were privately insured were diagnosed with early-stage cancer, compared to less than 35 percent of those who were uninsured.
• Among white women diagnosed with all stages of breast cancer, 76 percent of those who were uninsured survived five years, compared with 89 percent of those with private insurance; among African Americans, five-year survival rates were 65 percent for uninsured and 81 percent for privately insured women; among Hispanics, five-year survival rates were 83 percent for uninsured and 86 percent for privately insured women.
• Differences in survival between privately insured and uninsured women were seen for all stages of breast cancer.

For colorectal cancer, the report found that:

• Among men and women aged 50 to 64 years with private insurance, nearly half (48.3 percent) had had a recommended colorectal cancer screening test in the past ten years compared with fewer than one in five (18.8 percent) of those who were uninsured.
• Patients without health insurance were more likely than those with private insurance to be diagnosed with Stage IV and less likely to be diagnosed with Stage I colorectal cancer.
• Among whites, 50 percent of uninsured patients survived colorectal cancer for five years, compared to 66 percent who had private insurance; among African Americans, five-year survival rates were 41 percent among the uninsured compared with 60 percent of privately insured patients; among Hispanics, 57 percent of patients with no insurance survived five years compared with 63 percent of privately insured patients.
• Differences in survival between privately insured and uninsured patients were seen for all stages of colorectal cancer.
• Privately insured patients diagnosed with Stage II colorectal cancer were more likely to survive 5 years than uninsured patients diagnosed with Stage I.

Other findings from the study:

• Women between 40 and 64 without insurance were less likely than women with private insurance to have had a Pap test in the past three years (68 percent versus 87.9 percent).
• More than one in three privately insured men (37.1 percent) aged 50 to 64 years had received a prostate specific antigen test versus just one in seven (14 percent) uninsured men.
• Among individuals under age 65 years, those aged 18 to 24 years have the highest probability of being uninsured.
• The probability of being uninsured varies inversely by income.
• African Americans, Hispanics, Asian American/Pacific Islanders, and American Indian/Alaska Natives are much more likely to be uninsured than non-Hispanic Whites.
• More than half (53.6 percent) of uninsured individuals aged 18 to 64 years have no usual source of health care.
• The uninsured are more likely to report that cost issues caused them to delay care, not receive care, and not obtain prescription drugs.
• Among those who saw a health care practitioner, the uninsured were less likely to be advised to quit smoking or to lose weight.

"As our nation's investments in cancer research provide greater understanding of how to prevent cancer, detect it early, and treat it effectively, access to health care becomes even more important to the American Cancer Society's goal of eliminating cancer as a major public health problem," said Otis Brawley, M.D., chief medical officer of the American Cancer Society. "This report clearly suggests that insurance and cost-related barriers to care are critical to address if we want to ensure that all Americans are able to share in the progress we have achieved by having access to high-quality cancer prevention, early detection, and treatment services."

"These findings put insurance status squarely on the table as an important factor in cancer care disparities," said Elizabeth Ward, Ph.D., director of surveillance research and co-author of the report. "It's important to note that although variations in health insurance coverage likely contribute to racial and ethnic disparities in cancer outcomes, those disparities persist for several outcomes even when differences in insurance status are accounted for. So even if health insurance and financial barriers can be overcome, further research and interventions will be needed to address these other barriers."

"The truth is that there are gaping holes in our health care safety net and that most of these safety-net services are neither effective nor efficient in providing chronic-disease prevention, detection, or treatment," writes Elmer Huerta, M.D., American Cancer Society president, in an accompanying editorial. "The truth is that our national reluctance to face these facts is condemning thousands of people to die from cancer each year and thousands more to die of other diseases," adding that "[f]or too many hardworking 'average Americans,' paying for cancer treatment means not paying rent, mortgage (resulting in foreclosure or eviction), or utility bills, or even going hungry."

The report appears in the January/February issue of CA: A Cancer Journal for Clinicians, a peer-reviewed journal of the American Cancer Society.

Article: "Association on Insurance with Cancer Care Utilization and Outcomes," , E Ward, M Halpern, N Schrag, V Cokkinides, C DeSantis, P Bandi, R Siegel, A Stewart, A Jemal, CA Cancer J Clin 2008;58:9-31, DOI: 10.3322/CA.2007.0011