To examine the impact of race and insurance on survival among a large cohort of uterine cancer patients from the National Cancer Database (NCDB).
Women diagnosed with stages I-III uterine cancer between 2000 and 2001 were selected from the NCDB. Kaplan-Meier (KM) and multivariate Cox proportional hazards were used to estimate 4 year survival rates and hazard ratios (HR) and 95% confidence intervals (CIs), respectively.
Among the 39,510 evaluable patients, African Americans had a higher risk of death compared to whites (HR=1.43 95% CI 1.31-1.56) after adjusting for age, clinical and facility factors and zip code level education. After additional adjustment for treatment, the risk death decreased among African Americans (HR=1.33 95%CI 1.21-1.46) and subsequent adjustment for insurance further reduced the hazard of death (HR=1.28 95% CI 1.17-1.40). Patients with insurance other than private had an increased risk of death (uninsured HR=1.44 95% CI 1.20-1.72, Medicaid HR=1.70, 95% CI 1.46-1.99, Medicare among patients aged 18-64 HR=2.49, 95% CI 2.10-2.95, Medicare among patients aged 65-99 HR=1.22, 95% 1.11-1.34).
The largest contributors to African American/white survival disparities in this study were clinical factors, including stage at diagnosis, grade and histopathology. Patients without private health insurance had worse uterine cancer survival that may be improved through future health care reform aimed at improving access to preventive services and adequate treatment.
"And although SEER registries are geographically diverse, populations within their catchment area may come from more urban areas and have a larger proportion of foreign-born residents . Another limitation of our study was our inability to control for insurance status, which has been associated with cancer incidence [9, 16, 17], early detection [52–55], and survival outcomes [56–58]. A final caveat to our findings is our inability to control for the entire spectrum of treatment protocols (e.g., chemotherapy, hormone treatment, radiation dosing, etc.) as these data were not available in the SEER database. "
[Show abstract][Hide abstract] ABSTRACT: Background. Differentiated thyroid cancers (DTCs) are one of the most common and survivable cancers diagnosed in women. We examine factors associated with long-term survival and competing risks of death in women diagnosed with DTC under the age of 40 (<40) and aged 40 and older (40+). Methods. SEER data was used to identify DTCs diagnosed in women from 1975 to 2009. We examined overall (OS), disease-specific (DSS), other cancer (OCS), and non-cancer-related (NCS) survival using multivariate Cox proportional hazards modeling. Results. Observed survival was 97.2% for <40 (n = 14,540) and 82.5% for 40+ (n = 20,513). Distant stage (HR = 1.96, 95% CI 1.23-3.07), non-Hispanic Black (HR = 2.04, 95% CI 1.45-2.87), being unmarried (HR = 1.26, 95% 1.03-1.54), and subsequent primary cancers (HR = 4.63, 95% CI 3.76-5.71) were significant for OS in women <40. Age was an effect modifier for all survival outcomes. Racial disparities in NCS were most pronounced for young non-Hispanic black women (HR = 3.36, 95% CI 2.17-5.22). Women in both age groups were more likely to die from other causes. Conclusions. Age at diagnosis remains one of the strongest prognostic factors for thyroid cancer survival. More directed efforts to ensure effective care for comorbid conditions are needed to reduce mortality from other causes.
Journal of Cancer Epidemiology 10/2012; 2012(2):641372. DOI:10.1155/2012/641372
[Show abstract][Hide abstract] ABSTRACT: Screening can increase early detection and reduce rates of advanced-stage cancer. Uninsured patients have been shown to have lower rates of screening. Previous studies have shown that uninsured patients and patients with Medicaid present with more advanced stages of cancer. The aim of this study was to measure the effect of insurance status in the setting of a safety-net hospital.
Patients in our tumor registry with a diagnosis of breast or colorectal cancer between 2001 and 2010 were included. On the basis of their insurance status, they were divided into the following groups: Medicaid, Medicare, Medicare age < 65 years, commercial, uninsured, and unknown. Cancer stage was recorded for each patient, with stages III and IV considered advanced disease. The primary end point was the rate of advanced disease in each patient group.
A total of 910 patients were included in the study: 836 (91.9%) insured, 54 (5.9%) uninsured, and 20 (2.2%) unknown. Of the insured patients, 301 (36.0%) had Medicaid. Two hundred thirty-seven (30.7%) of 836 insured patients had advanced disease, compared with 27 (50.0%) of 54 uninsured patients (odds ratio, 1.63; P = .003). Of patients with Medicaid, 83 (27.6%) of 301 had advanced disease, which was not statistically different from patients with other insurance.
In a safety-net hospital, patients with Medicaid had rates of advanced-stage cancer similar to those in patients with other types of insurance. However, patients with no insurance had significantly higher rates of advanced disease. This has significant ramifications in view of the new health care law, which will convert many patients from being uninsured to having Medicaid.
Journal of Oncology Practice 05/2012; 8(3 Suppl):16s-21s. DOI:10.1200/JOP.2012.000542
[Show abstract][Hide abstract] ABSTRACT: While oncologists are aware that cancer treatments may impact fertility, referral rates for fertility preservation consultation (FPC) remain poor. The goal of this study was to identify predictors associated with FPC referral.
This is a retrospective, cohort study of women aged 18-42 years diagnosed with a new breast, gynecologic, hematologic or gastrointestinal cancer at our institution between January 2008 and May 2010. Exclusion criteria included history of permanent sterilization, documentation of no desire for future children, stage IV disease, short interval (<4 days) between diagnosis and treatment and treatment that posed no threat to fertility. Demographic, socioeconomic and cancer variables were evaluated with respect to FPC. Logistic regression was used to determine the odds of referral for FPC based on specified predictors.
One hundred and ninety-nine patients were eligible for FPC and of those, 41 received FPC (20.6%). Women with breast cancer were 10 times more likely to receive FPC compared with other cancer diagnoses [odds ratio (OR) 10.1; 95% confidence interval (CI) 3.8-26.8]. The odds of FPC referral were approximately two times higher for Caucasian women (OR 2.4; 95% CI 0.9-6.2), three times higher for age <35 years (OR 3.3; 95% CI 1.4-7.7) and four times higher in nulliparous women (OR 4.6; 95% CI 1.9-11.3). There was no association between BMI, income, distance to our institution, being in a relationship and referral for FPC.
Overall referral rates for FPC are low, and there appear to be significant discrepancies in referral based on ethnicity, age, parity and cancer type. This highlights a need for further provider education and awareness across all oncologic disciplines.
Human Reproduction 05/2012; 27(7):2076-81. DOI:10.1093/humrep/des133 · 4.57 Impact Factor
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