Financial Concerns and Lack of Insurance Affect Survival and Access to Care Among Cancer Patients

Roxanne Nelson

June 21, 2010

June 21, 2010 — There are approximately 12 million cancer survivors in the United States, and cost might be preventing more than 2 million of this group from getting needed medical care.

According to a study published online June 14 in Cancer, approximately 18% of cancer survivors did not get 1 or more needed medical services because of financial concerns.

"In this study, we identified an important issue in survivorship care; namely, that financial concerns may prevent cancer survivors, and particularly survivors [younger than] 65 years, from accessing needed medical services," write the authors, led by Kathryn E. Weaver, PhD, MPH, from Wake Forest University School of Medicine in Winston-Salem, North Carolina.

A second study, also published online June 14 in Cancer, found that the age-adjusted risk for death at 5 years was more than twice as high among rectal cancer patients without private insurance. The authors found that disparities in stage and treatment explained approximately 53% of the excess mortality seen among patients covered by Medicaid or no insurance at all; factors other than stage and treatment explained approximately 17%.

The disparities in stage and treatment were probably due to the fact that these patients sought treatment late and did not get recommended screening, explained lead author Anthony S. Robbins, MD, PhD, director of health services research at the American Cancer Society.

"They were less likely to get the appropriate treatment for whatever stage of cancer they were diagnosed with," he told Medscape Oncology.

"Our findings suggest that if the Medicaid-insured and insured patients had private insurance, many more of them would get diagnosed with early-stage cancer and many more would get appropriate stage-specific treatment."

Forgoing Medical Care Because of Cost

In the first study, the researchers analyzed data from the annual US National Health Interview Survey (NHIS) from 2003 to 2006, and identified 6602 adult cancer survivors and 104,364 individuals with no history of cancer. They also evaluated self-reports of forgoing medical care services because of cost, and whether cancer history and race/ethnicity were associated with the likelihood of forgoing medical care.

They found that among cancer survivors, the prevalence of forgoing or delaying care because of cost concerns overall was about 18%. The prevalence of forgoing medical care was 7.8% (95% confidence interval [CI], 7.1% - 8.6%); of delaying medical care was 10.7% (95% CI, 9.8% - 11.6%); of forgoing prescription medication was 9.9% (95% CI, 9.1% - 10.8%); of forgoing dental care was11.3% (95% CI, 10.4% - 12.2%); and of forgoing mental healthcare was 2.7% (95% CI, 2.3% - 3.2%).

Compared with those without a history of cancer, survivors younger than 65 years of age were 1.49 to 1.95 times more likely to forgo or delay medical services (P < .05). The authors note that this finding is consistent with earlier research that examined healthcare access in younger survivors using the NHIS.

After adjustment for factors such as sex, education, health insurance coverage, and comorbid medical conditions, the effect of cancer history was reduced but not eliminated. Conversely, the authors observed that among individuals 65 years and older, there were no significant differences between cancer survivors and control subjects in either the unadjusted or adjusted model.

There were also disparities in race and ethnicity, although adjustment for sex, education, insurance coverage, and comorbidities either reversed or eliminated ethnic disparities in outcomes that were observed in unadjusted models. After adjustment, the authors note that black and Hispanic individuals without a cancer diagnosis were less likely than survivors to forgo medical and mental healthcare and to delay medical care.

Although black cancer survivors were more likely to forgo prescription medications and dental care than white survivors, the interaction between cancer history and race/ethnicity was not statistically significant for comparisons between blacks and whites. This suggests, the authors note, similar patterns between adults with and without a history of cancer.

Medicaid and No Insurance Play Role in Survival

In the second study, Dr. Robbins and colleagues examined the role that stage, treatment, and several other factors play in survival disparities that have been observed in colorectal cancer. The researchers limited their study to rectal cancer, because it is staged and treated differently from colon cancer and because previous research is more limited than for colon cancer.

Using data from the National Cancer Data Base, the authors identified 19,154 rectal cancer patients between the ages of 18 and 64 years, and assessed the impact on 5-year survival of age, sex, race/ethnicity, histologic grade, histologic subtype, neighborhood education and income levels, facility type, stage, and treatment.

Overall, patients without private insurance were far more likely to be diagnosed with stage IV cancer and much less likely to be diagnosed with stage I cancer. In addition, patients covered by Medicaid or without insurance were substantially less likely to receive standard therapies than those with private insurance. For example, 95% of privately insured patients with stage I disease underwent surgery, compared with 83% of uninsured patients; among patients with stage IV disease, 15% of uninsured patients received no treatment, compared with 4% of those with private insurance.

The authors found that on multivariate analysis, all prognostic factors were significant independent predictors of 5-year survival. When adjusted for age, Medicaid patients and those without insurance were more than twice as likely to die within 5 years as patients with private insurance.

When the data were adjusted for all factors except stage and treatment, the hazard ratios (HR) were 1.88 (95% CI, 1.72 - 2.04) for Medicaid patients and 1.84 (95% CI, 1.69 - 2.01) for uninsured patients. After further adjustment for stage and treatment, HRs were 1.34 (95% CI, 1.22 - 1.46) for Medicaid patients and 1.29 (95% CI, 1.18 - 1.42) for uninsured patients.

The results of this study provide "substantial evidence that poorer survival among cancer patients without private insurance is largely attributable to later stage at diagnosis and inadequate treatment," note the authors, who add that these factors could be "modifiable through healthcare reform."

"Addressing insurance-related and cost-related barriers to high-quality prevention, early detection, and treatment may not be the only measure that will be needed to eliminate cancer disparities, but our data suggest that these barriers may be particularly important," they conclude.

None of the authors in either study have disclosed no relevant financial relationships.

Cancer. Published online June 14, 2010. Abstract, Abstract

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