Health insurance status and head and neck cancer diagnoses, outcomes

Drawing on the National Cancer Institute's Survival, Epidemiology and End Results (SEER) database, researchers examined clinical, demographic and socioeconomic variables in the records of all 53,848 patients diagnosed with primary squamous cell carcinoma of the oral cavity, pharynx or larynx between 2007 and 2012. Patients were divided into three cohorts based on health insurance status: patients with non-Medicaid insurance (80.1 percent), patients with Medicaid (15 percent), and patients who were uninsured (4.9 percent).

Head and neck cancer patients with and without insurance differed significantly from each other in terms of disease stage at time of diagnosis, treatment practices and survival rates. Uninsured and Medicaid patients, compared to insured patients, were more likely to present with advanced disease, such as larger tumors or more extensive lymph node involvement, were less likely to receive RT, and had higher mortality rates following cancer.

Specifically, uninsured patients and Medicaid patients, compared to insured patients, were more likely to present with American Joint Committee on Cancer Stage III or IV disease (75.1 percent uninsured, 72.9 percent Medicaid, 60.1 percent insured; p < .001). These patients also were less likely to receive external beam RT (Odds Ratio (OR) for uninsured, 0.68; OR for Medicaid, 0.77; both p < .05), and uninsured patients were less likely to receive cancer directed surgery (OR, 0.86; p < .05).

Perhaps most alarmingly, rates of both overall mortality and cause-specific mortality were higher for uninsured and Medicaid patients, indicating that this subset of head and neck cancer patients is particularly vulnerable to cancer-related death. Odds ratios for uninsured and Medicaid patients, respectively, were 1.48 and 1.55 for overall mortality and 1.65 and 1.60 for cause-specific mortality, compared to those for patients with insurance.

"We were surprised by the similarity in outcomes among the uninsured patients and Medicaid patients," said Thomas M. Churilla, MD, a resident physician in radiation oncology at the Fox Chase Cancer Center in Philadelphia and lead author on the study. "These findings suggest that other risk factors and barriers to care, in addition to health insurance coverage, are responsible for survival differences from head and neck cancers."

Researchers used multiple logistic regression for analyses examining treatment directives to adjust for clinical and demographic covariates, including disease site, disease stage, age, race, location, education, income, use of RT (for the surgery analysis) and use of cancer directed surgery (for the RT analysis). Cancer-specific mortality analyses used the Kaplan-Meier method and adjusted for these covariates using Cox regression.

"Access to cancer care is a complex topic, and further study is necessary to determine what mix of patient, provider and disease-related factors are responsible for this disparity in mortality rates. Based on our study, expansions in Medicaid may not significantly affect outcomes for head and neck cancer patients unless we also explore and address these other underlying factors," said Dr. Churilla.