Article

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: 1.43). 03/2008; 14(2):128-34. DOI: 10.1111/j.1524-4741.2007.00542.x
Source: PubMed

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.

0 Bookmarks
 · 
77 Views
  • [Show abstract] [Hide abstract]
    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 · 5.88 Impact Factor
    This article is viewable in ResearchGate's enriched format
  • [Show abstract] [Hide abstract]
    ABSTRACT: Hormone receptor-positive (HR+) cancers account for most breast cancer diagnoses and deaths. Among survivors with HR + breast cancers, endocrine therapy (ET) reduces 5-year risk of recurrence by up to 40 %. Observational studies in Medicare- and privately-insured survivors suggest underutilization of ET. We sought to characterize ET use in a low-income Medicaid-insured population in North Carolina. Medicaid claims data were matched to state cancer registry records for survivors aging 18-64 diagnosed with stage 0-II HR + breast cancer from 2003 to 2007, eligible for ET, and enrolled in Medicaid for at least 12 of 15 months post-diagnosis. We used multivariable logistic regression to model receipt of any ET medication during 15 months post-diagnosis controlling for age, race, tumor characteristics, receipt of other treatments, comorbidity, residence, reason for Medicaid eligibility, involvement in the Breast and Cervical Cancer Control Program (BCCCP), and diagnosis year. Of 222 women meeting the inclusion criteria, only 50 % filled a prescription for ET. Involvement in the BCCCP and earlier year of diagnoses were associated with significantly higher odds of initiating guideline-recommended ET (adjusted odds ratio [AOR] for the BCCCP 3.76, 95 % confidence interval [CI] 1.67-8.48; AOR for 2004 relative to 2007 2.80, 95 % CI 1.03-7.62; AOR for 2005 relative to 2007 2.11, 95 % CI 0.92-4.85). Results suggest substantial underutilization of ET in this population. Interventions are needed to improve timely receipt of ET and to better support survivors taking ET. Low-income survivors should be counseled on the importance of ET and offered support services to promote initiation and long-term adherence.
    Journal of Cancer Survivorship 05/2014; 8(4). DOI:10.1007/s11764-014-0365-3 · 3.29 Impact Factor
  • [Show abstract] [Hide abstract]
    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; 2013:742462. DOI:10.1155/2013/742462
    This article is viewable in ResearchGate's enriched format