C. M. Kiernan1, K. Idrees2, N. B. Merchant2, A. A. Parikh2 1Vanderbilt University Medical Center,General Surgery,Nashville, TN, USA 2Vanderbilt University Medical Center,Surgical Oncology,Nashville, TN, USA
Introduction:
Prior studies have demonstrated that uninsured or underinsured cancer patients are more likely to receive substandard treatment and to have worse outcomes. The purpose of this study was to evaluate the impact of type of health insurance on treatment and survival in colon cancer patients, utilizing a large population database.
Methods:
Using the National Cancer Database, we identified 702,892 patients diagnosed with colon cancer from 2003-2011. Patients were stratified into 5 cohorts: Private, Medicare, Military, Medicaid, and Uninsured to test the association of health insurance type with receipt of adjuvant chemotherapy (2003-2011) in patients with stage 3 disease by multivariable logistic regression as well as overall survival in patients with stage 1, 2 and 3 disease by Cox-Proportional regression. Patients with metastatic disease were excluded.
Results:
Within the cohorts of the Uninsured and Medicaid-insured, a higher proportion of patients were African American (AA) or Hispanic. Patients in these cohorts were more likely to present with higher stage tumors, were more often treated at academic centers, and were less likely to undergo surgical resection (p<0.001). By multivariable analysis, stage III patients who were uninsured [OR 0.55, 0.51-0.60, p<0.001], on Medicaid [OR 0.51, CI 0.51-0.60, p<0.001], or AA [OR 0.82, CI 0.79-0.85, p<0.001] were less likely to receive adjuvant chemotherapy. By Cox-Proportional regression, lack of insurance [HR 1.64, CI 1.54-1.75, p <0.001], Medicaid [HR 1.80, CI 1.71-1.90, p<0.001], Medicare [HR 1.08, CI 1.05-1.10, p<0.001], military insurance [HR 1.20, CI 1.05-1.37], AA race [HR 1.24, CI 1.20-1.27, p<0.001], as well as stage 2 [HR 1.47, CI 1.43-1.50, p<0.001] and stage 3 [HR 2.35, CI 2.29-2.41, p<0.001] disease were independently associated with worse overall survival.
Conclusion:
In addition to racial disparities, insurance disparities contribute to inequality in the utilization and distribution of health care. Uninsured and Medicaid patients present with advanced stage disease, appear less likely to undergo surgical resection or receive adjuvant chemotherapy, and have worse overall survival. Insurance disparities should be further investigated and followed, independent of race, as the healthcare climate in the US changes and evolves.