Treatment Variation by Insurance Status for Breast Cancer Patients

University of Toronto, Division of Surgical Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
The Breast Journal (Impact Factor: 1.41). 03/2008; 14(2):128-34. DOI: 10.1111/j.1524-4741.2007.00542.x
Source: PubMed


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.

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    • "First, income has been observed to be strongly associated with breast cancer care and survival in the United States, but not in Canada ( Gillan et al., 2012; Gorey, 2009; McKenzie & Jeffreys, 2009). Second, in the United States women with private health insurance or Medicare coverage are more likely to receive better care than are women with arguably less adequate coverage, such as that provided through the Medicaid programs of many states, or none ( Coburn et al., 2008; Gorey et al., 2013; Schueler, Chu, & Smith-Bindman, 2008; Subramanian et al., 2011). And third, studies of breast cancer survival in Canada and the United States have consistently observed better survival in Canada among the poor, but no systematic differences within middle or upper socioeconomic strata ( Gorey, 2009). "
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    ABSTRACT: This historical study estimated the protective effects of a universally accessible, single-payer health care system versus a multipayer system that leaves many uninsured or underinsured by comparing breast cancer care of women living in high-poverty neighborhoods in Ontario and California between 1996 and 2011. Women in Canada experienced better care, particularly as compared with women who were inadequately insured in the United States. Women in Canada were diagnosed earlier (rate ratio [RR] = 1.12) and enjoyed better access to breast conserving surgery (RR = 1.48), radiation (RR = 1.60), and hormone therapies (RR = 1.78). Women living in high-poverty Canadian neighborhoods even experienced shorter waits for surgery (RR = 0.58) and radiation therapy (RR = 0.44) than did such women in the United States. Consequently, women in Canada were much more likely to survive longer. Regression analyses indicated that health insurance could explain most of the better care and better outcomes in Canada. Over this study’s 15-year time frame 31,500 late diagnoses, 94,500 suboptimum treatment plans, and 103,500 early deaths were estimated in high-poverty U.S. neighborhoods due to relatively inadequate health insurance coverage. Implications for social work practice, including advocacy for future reforms of U.S. health care, are discussed.
    Social work research 05/2015; 39(2). DOI:10.1093/swr/svv006 · 0.88 Impact Factor
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    • "Although explanations for SES differences in survival are not well documented, advanced stage at diagnosis has been the most cited explanatory factor [32,33]—perhaps because of screening disparities among women age 40 to 79 years [34]—and increasing evidence suggests inadequate breast cancer treatment and follow-up care among patients in lower SES groups [33]. Furthermore, recent evidence suggests that disparities in breast cancer treatment modalities are associated with health insurance status [35-37], a measure we found to be associated with survival in our study. Factors related to treatment receipt and stage at diagnosis, however, have not been found to explain fully the socioeconomic disparities in survival [32,33,38,39]. "
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    ABSTRACT: Young women have poorer survival after breast cancer than older women. It is unclear whether this survival difference relates to the unique distribution of hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2) defined molecular breast cancer subtypes among adolescent and young adult (AYA) women aged 15--39 years. The purpose of our study was to examine associations between breast cancer subtypes and short-term survival in AYA women, as well as determine whether the distinct molecular subtype distribution among AYA women explains the unfavorable overall breast cancer survival statistics reported for AYA women compared to older women. Data for 5,331 AYA breast cancers diagnosed between 2005 and 2009 were obtained from the California Cancer Registry. Survival by subtype (triple-negative; HR+/HER2-; HR+/HER2+; HR-/HER2+) and age-group (AYA versus 40 to 64 year olds) was analyzed with Cox proportional hazards regression with follow-up through 2010. With up to 6 years of follow-up and a mean survival time of 3.1 years (SD = 1.5 years), AYA women diagnosed with HR-/HER + and triple-negative breast cancer experienced a 1.6-fold and 2.7-fold increased risk of death, respectively, from all causes (HR-/HER + hazard ratio: 1.55; 95% confidence interval (CI): 1.10, 2.18; triple negative HR: 2.75; 95% CI: 2.06, 3.66) and breast cancer (HR-/HER + hazard ratio: 1.63; 95% CI: 1.12, 2.36; triple negative hazard ratio: 2.71; 955 CI: 1.98, 3.71) than AYA women with HR+/HER2- breast cancer. AYA women who resided in lower socioeconomic status neighborhoods, had public health insurance and were of Black, compared to White, race/ethnicity experienced worse survival. This race/ethnicity association was attenuated somewhat after adjusting for breast cancer subtypes (hazard ratio: 1.33; 95% CI: 0.98, 1.82). AYA women had similar all-cause and breast cancer-specific short-term survival as older women for all breast cancer subtypes and across all stages of disease. Among AYA women with breast cancer, short-term survival varied by breast cancer subtypes, with the distribution of breast cancer subtypes explaining some of the poorer survival observed among Black, compared to White, AYA women. Future studies should consider whether distribution of breast cancer subtypes and other factors, including differential receipt of treatment regimens, influence long-term survival in young compared with older women.
    Breast cancer research: BCR 10/2013; 15(5):R95. DOI:10.1186/bcr3556 · 5.49 Impact Factor
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    • "Besides, lower proportion of BCT and OBS is performed among the patients without insurance or medicaid support. The presentation of BC is worse in these women as well [62]. "
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    ABSTRACT: Surgical management of breast cancer has evolved considerably over the last two decades. There has been a major shift toward less-invasive local treatments, from radical mastectomy to breast-conserving therapy (BCT) and oncoplastic breast surgery (OBS). In order to investigate the efficacy of each of the three abovementioned methods, a literature review was conducted for measurable outcomes including local recurrence, survival, cosmetic outcome, quality of life (QOL), and health economy. From the point of view of oncological result, there is no difference between mastectomy and BCT in local recurrence rate and survival. Long-term results for OBS are not available. The items assessed in the QOL sound a better score for OBS in comparison with mastectomy or BCT. OBS is also associated with a better cosmetic outcome. Although having low income seems to be associated with lower BCT and OBS utilization, prognosis of breast cancer is worse in these women as well. Thus, health economy is the matter that should be studied seriously. OBS is an innovative, progressive, and complicated subspeciality that lacks published randomized clinical trials comparing surgical techniques and objective measures of outcome, especially from oncologic and health economy points of view.
    09/2013; 2013(1):742462. DOI:10.1155/2013/742462
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