The Association Between Insurance Status and Prostate Cancer Outcomes

Implications for the Affordable Care Act

BA Mahal; AA Aizer; DR Ziehr; AS Hyatt; C Lago-Hernandez; Y-W Chen; TK Choueiri; JC Hu; CJ Sweeney; CJ Beard; AV D'Amico; NE Martin; Q-D Trinh; PL Nguyen


Prostate Cancer Prostatic Dis. 2014;17(3):273-279. 

In This Article

Abstract and Introduction


Background: The Affordable Care Act (ACA) aims to expand health insurance coverage to over 30 million previously uninsured Americans. To help evaluate the potential impact of the ACA on prostate cancer care, we examined the associations between insurance coverage and prostate cancer outcomes among men <65 years old who are not yet eligible for Medicare.

Methods: The Surveillance, Epidemiology and End Results Program was used to identify 85 203 men aged <65 years diagnosed with prostate cancer from 2007 to 2010. Multivariable logistic regression modeled the association between insurance status and stage at presentation. Among men with high-risk disease, the associations between insurance status and receipt of definitive therapy, prostate cancer-specific mortality (PCSM) and all-cause mortality were determined using multivariable logistic, Fine and Gray competing-risks and Cox regression models, respectively.

Results: Uninsured patients were more likely to be non-white and come from regions of rural residence, lower median household income and lower education level (P<0.001 for all cases). Insured men were less likely to present with metastatic disease (adjusted odds ratio (AOR) 0.23; 95% confidence interval (CI) 0.20–0.27; P<0.001). Among men with high-risk disease, insured men were more likely to receive definitive treatment (AOR 2.29; 95% CI 1.81–2.89; P<0.001), and had decreased PCSM (adjusted hazard ratio 0.56; 95% CI 0.31–0.98; P=0.04) and all-cause mortality (adjusted hazard ratio 0.60; 0.39–0.91; P=0.01).

Conclusions: Insured men with prostate cancer are less likely to present with metastatic disease, more likely to be treated if they develop high-risk disease and are more likely to survive their cancer, suggesting that expanding health coverage under the ACA may significantly improve outcomes for men with prostate cancer who are not yet eligible for Medicare.


Before the implementation of the Affordable Care Act (ACA), ~16.7% of the US population lived without health insurance coverage.[1] The ACA represents a major landmark and overhaul of the health-care system and with its implementation, a large proportion of the US population who was previously uninsured should now be eligible for insurance.[2] Specifically, the ACA aims to expand insurance coverage (including Medicaid) to over 30 million previously uninsured patients, leaving just under 25 million uninsured once all provisions take place.[2,3]

The expansion of health-care coverage will likely make its effect known in the immediate future, especially in diseases with the greatest burden.[4–6] Prostate cancer represents the most common nonskin cancer in men and it is estimated that there will be 238 590 new cases of prostate cancer and 29 480 deaths because of prostate cancer in the United States in 2014.[7] There is currently little literature examining the influence of insurance status on prostate cancer-specific outcomes in large contemporary national cohorts. With the ongoing debates about the value of expansion of insurance coverage under the ACA in the United States, it is critically important to understand and study the relationship between insurance status and cancer-specific outcomes.

Therefore, we used the Surveillance, Epidemiology, and End Results (SEER) database to evaluate the association between insurance status and prostate cancer care and outcomes among patients who are not yet Medicare eligible. We hypothesize that insurance coverage will have beneficial impacts on stage at presentation, treatment rates and overall and cancer-specific survival among men with prostate cancer.