Advances in the prevention, early detection, and treatment of cancer have resulted in an almost 14% decrease in the death rates from all cancers combined from 1991 to 2004 in the overall US population, with remarkable declines in mortality for the top 3 causes of cancer death in men (lung, colorectal, and prostate cancer) and 2 of the top 3 cancers in women (breast and colorectal cancer). However, not all segments of the population have benefited equally from this progress, and evidence suggests that some of these differences are related to lack of access to health care. Lack of adequate health insurance appears to be a critical barrier to receipt of appropriate health care services. This article provides an overview of systems of health insurance in the United States, demographic and socioeconomic characteristics associated with health insurance coverage, and economic burdens related to health care among individuals and families. This article also 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 and the National Cancer Data Base. Although this article focuses on associations between health insurance and cancer care utilization and outcomes, it is important to recognize that barriers to receipt of optimal cancer care are complex and involve patient-level, provider, and health system factors. Evidence presented in this paper suggests that addressing insurance and cost-related barriers to care is a critical component of efforts to ensure that all Americans are able to share in the progress that can be achieved by access to high-quality cancer prevention, early detection, and treatment services. (CA Cancer J Clin 2008;58:9-31.)

No abstract

BACKGROUND.Although patients who have early‐stage oropharyngeal cancer can be treated with little impairment of function, the treatment of advanced disease can result in decreased quality of life and mortality. Patients without insurance and with other barriers to access to care may delay seeking medical attention for early symptoms, resulting in more advanced disease at presentation. In this study, the authors examined whether patients who had no insurance or who were covered by Medicaid insurance were more likely to present with advanced oropharyngeal cancer.METHODS.In this retrospective cohort study from the National Cancer Database from 1996 to 2003, patients with known insurance status who were diagnosed with invasive oropharyngeal cancer at Commission on Cancer facilities (n = 40,487) were included. Adjusted and unadjusted logistic regression models were used to analyze the likelihood of presenting with more advanced stage disease.RESULTS.After controlling for other sociodemographic characteristics, patients with advanced oropharyngeal cancer at diagnosis were more likely to be uninsured (odds ratio [OR], 1.37; 95% confidence interval [95% CI], 1.21–1.25) or covered by Medicaid (OR, 1.31; 95% CI, 1.19–1.46) compared with patients who had private insurance. Similarly, patients were most likely to present with the largest tumors (T4 disease) if they were uninsured (OR, 2.82; 95% CI, 2.46–3.23) or covered by Medicaid (OR, 2.95; 95% CI, 2.63–3.31). They also were more likely to present with the greatest degree of lymph node involvement (N3) if they were uninsured (OR, 2.06; 95% CI, 1.76–2.40) or covered by Medicaid (OR, 1.66; 95% CI, 1.45–1.90).CONCLUSIONS.Individuals who lacked insurance or had Medicaid coverage were at the greatest risk for presenting with advanced oropharyngeal cancer. In the current study, the results for the Medicaid group may have been influenced by the postdiagnostic enrollment of uninsured patients. Insurance coverage appeared to be a highly modifiable predictor of cancer stage. The findings indicated that it is important to consider the impact of insurance coverage on disease stage at diagnosis and associated morbidity, mortality, and quality of life. Cancer 2007. © 2007 American Cancer Society.

Persons living in the United States who lack private medical insurance are less likely to have access to medical care and to take part in cancer screening programs. Regional studies suggest that uninsured and Medicaid-insured individuals are likelier than those who are privately insured to present with advanced-stage cancer, but this has not been confirmed using contemporary national-level information. Complicating the problem is the observation that cancer patients from ethnic minorities are likelier than non-Hispanic whites to be uninsured or Medicaid insured. This study sought relationships between insurance status and disease stage at the time of diagnosis for twelve cancer sites (breast, colorectal, kidney, lung, melanoma, non-Hodgkin lymphoma, ovary, pancreas, prostate, urinary bladder, uterus, thyroid). The study population included 3,742,407 patients whose characteristics resembled those of the U.S. population not included in the analysis. The patients, diagnosed in the years 1998-2004, were enrolled in the U.S. National Cancer Database, a hospital-based registry with patient information from approximately 1430 facilities.Uninsured and Medicaid-insured patients were significantly more likely than privately insured patients to present with advanced-stage (stage III or stage IV) cancer. The relationship was most evident for patients whose cancers can potentially be detected at an early stage by symptom assessment or screening. They include breast and colorectal cancers, lung cancer, and melanoma. Compared with privately insured patients, the odds ratios (ORs) for advanced-stage disease at diagnosis for uninsured and Medicaid-insured patients with colorectal cancer were 2.0 (95% confidence interval, 1.9-2.

Differential scanning calorimetry (DSC) was used to evaluate the thermal behavior and isothermal crystallization kinetics of poly(ethylene terephthalate) (PET) copolymers containing 2‐methyl‐1,3‐propanediol as a comonomer unit. The addition of comonomer reduces the melting temperature and decreases the range between the glass transition and melting point. The rate of crystallization is also decreased with the addition of this comonomer. In this case it appears that the more flexible glycol group does not significantly increase crystallization rates by promoting chain folding during crystallization, as has been suggested for some other glycol‐modified PET copolyesters. The melting behavior following isothermal crystallization was examined using a Hoffman–Weeks approach, showing very good linearity for all copolymers tested, and predicted an equilibrium melting temperature (Tm0) of 280.0°C for PET homopolymer, in agreement with literature values. The remaining copolymers showed a marked decrease in Tm0 with increasing copolymer composition. The results of this study support the claim that these comonomers are excluded from the polymer crystal during growth. © 2006 Wiley Periodicals, Inc. J Appl Polym Sci 100: 2592–2603, 2006

Objective:To examine whether patients with no insurance or Medicaid are more likely to present with advanced-stage laryngeal cancer.Design: Retrospective cohort study from the National Cancer Database, 1996Database, -2003 Setting: Hospital-based practice.Participants: Patients with known insurance status diagnosed as having invasive laryngeal cancer at Commission on Cancer facilities (N=61 131) were included. Adjusted and unadjusted logistic regression models analyzed the likelihood of presenting at a more advanced stage. Main Outcome Measures: Overall stage of laryngeal cancer (early vs advanced) and tumor size (T stage) at diagnosis. Results: Patients with advanced-stage laryngeal cancer at diagnosis were more likely to be uninsured (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.79-2.15) or covered by Medicaid (OR, 2.40; 95% CI, 2.21-2.61) compared with those with private insurance. Similarly, patients were most likely to present with the largest tumors (T4 disease) if they were uninsured (OR, 2.92; 95% CI, 2.60-3.28) or covered by Medicaid (OR, 3.97; 95% CI,. Patients who were black, between ages 18 and 56 years, and who resided in zip codes with low proportions of high school graduates or low median household incomes were also more likely to be diagnosed as having advanced disease and/or larger tumors.Conclusions: Individuals lacking insurance or having Medicaid are at greatest risk for presenting with advanced laryngeal cancer. Results for the Medicaid group may be influenced by the postdiagnosis enrollment of uninsured patients. It is important to consider the impact of insurance coverage on stage at diagnosis and associated morbidity, mortality, quality of life, and costs.

Our results suggest that chemoradiation is increasingly becoming more prevalent at all facility types. The use of radiation alone as primary treatment significantly declined during the study period. In view of the complexity and multidisciplinary nature of treatment for oropharyngeal cancer, it is recommended that care of such patients be discussed at institutional tumor boards and that the recommendations be systematically recorded and documented in hospital cancer registries.

The use of chemoradiation increased after the 1991 publication. It was impossible to determine from the NCDB whether additional patients who could benefit from chemo-RT were not offered or did not complete this treatment option. We recommend that treatment recommendations discussed at tumor boards be recorded in cancer registries.