Treatment Variation by Insurance Status for Breast Cancer Patients

Abstract

Few studies have examined the relationship of insurance status with the presentation and treatment of breast cancer. Using a state cancer registry, we compared tumor presentation and surgical treatments at presentation by insurance status (private insurance, Medicare, Medicaid, or uninsured). Student's t-test, Chi-square test, and ANOVA were used for comparison. P-values reflect a comparison to insured patients. From 1996 to 2005, there were 6876 cases of invasive breast cancer with either private (n = 3975), Medicare (n = 2592), Medicaid (n = 193), or no insurance (n = 116). The median age (years) at presentation was 55 for private, 76 for Medicare, 54 for Medicaid and 54 for uninsured. The mean and median tumor size (mm) were 18.5 and 15 for private; 20.9 and 15 for Medicare; 24.2 and 18 for Medicaid; and 29.5 and 17 for uninsured, respectively; (p < 0.001 for all). Fewer women with Medicare and Medicaid presented with node negative breast cancers: private, 73.4% node negative; Medicare, 79.5% (p < 0.001); Medicaid, 60.9% (p < 0.001); and uninsured, 58% (p = 0.005). Significantly more uninsured women had no surgical treatment of their breast cancer: 15.5% versus 4.3% for private (p < 0.001). Among women with non-metastatic T1/T2 tumors, 71.5% with private insurance underwent breast-conserving surgery (BCS), compared with 64.2% of Medicare (p < 0.001), 65% of Medicaid (p = 0.097), and 65.4% of uninsured (p = 0.234). The rate of reconstruction following mastectomy was higher for private insurance (36.6%), compared with Medicare (3.8%, p < 0.0001), Medicaid (26.1%, p = 0.31), and uninsured (5.0%, p = 0.0038). The presentation of breast cancer in women with no insurance and Medicaid is significantly worse than those with private insurance. Of concern are the lower proportions of BCS and reconstruction among patients who are uninsured or have Medicaid. Reduction of disparities in breast cancer presentation and treatment may be possible by increasing enrollment of uninsured, program-eligible women in a state-supported screening and treatment program.

Breast cancer care in the Canada and the United States: Ecological comparisons of extremely impoverished and affluent urban neighborhoods

“…These findings, along with the regressionbased suggestion that breast cancer care-survival relationships are largely mediated by income extremes in the United States, but not in Canada seem to most parsimoniously indict inadequate health insurance coverage among America's extremely poor. In fact, this study's findings seem extraordinarily convergent with US studies that have consistently observed strong relationships between low-income, various under-and uninsured statuses, and relatively later stage at breast cancer diagnosis, lack of treatment access and early death (Anderson and Eamon, 2005;Chen et al, 2008a;Coburn et al, 2008;Griggs et al, 2007;Hahn et al, 2007;Purc-Stephenson and Gorey, 2008;Studts et al, 2006;Ward et al, 2008). It is likely that the differential outcomes this study observed will persist until medical coverage and the best available care is made available to all Americans with cancer (Freedman, 2004).…”

Wait times for surgical and adjuvant radiation treatment of breast cancer in Canada and the United States: Greater socioeconomic inequity in America

“…While a very modest to null association between SES and breast cancer survival has been observed in Canada where necessary medical care is universally covered. [18][19][20] Critical betweencountry comparisons have also been consistent with the health insurance explanation, 21,22 demonstrating particular Canadian survival advantages among residents of the lowest income areas. 18,19 Consistent with this well known international SES-breast cancer survival pattern, we hypothesized the following: (1) Within-country: Wait times for initial surgery and adjuvant RT would be associated with SES in the US (lower SES would wait longer), but not in Canada.…”

Evolving Trends in Autologous Breast Reconstruction

“…Some authors suggest that cost savings could be gained by performing these complex procedures only at high-volume centers, which have decreased hospital charges both in the setting of reconstruction complications and without, a finding recently identified by Albornoz et al 15 in regard to immediate autologous breast reconstruction. One of the interesting findings of this study is insurance coverage trends for patients undergoing DIEP f laps; these patients 25 but it is perhaps surprising that the type of reconstruction the patient receives is correlated with insurance status. It should be noted that, if more than 1 payer is listed for a hospital discharge, only the first-listed payer is reported in the HCUP NIS for classifying insurance status; this may overestimate or underestimate insurance coverage for this cohort.…”