Less Than Optimal Care for Cancer in Uninsured and Medicaid Patients

Pam Harrison

August 09, 2016

More research continues to show that the uninsured and those covered only by Medicaid present with more advanced and higher-risk cancers, are less likely to receive guideline-based care, and are more likely to die of their disease than the fully insured, two separate studies indicate.

Both studies were published online August 8 in Cancer.

"Clinical outcomes are not solely a function of the patient's clinical status," note Michael T. Halpern, MD, PhD, Temple University College of Public Health, Philadelphia, Pennsylvania, and Otis W. Brawley, MD, Emory University, Atlanta, George, in an accompanying editorial.

Adequate health care should be considered an inalienable human right. Dr Michael Halpern and Dr Otis Brawley

"Adequate health care should be considered an inalienable human right, and greater emphasis is needed on realizing strategies that will make this happen throughout the continuum of cancer care," they add. "Overcoming disparities and promoting health equity may be the most expedient way to improve outcomes for individuals diagnosed with cancer."

Testicular Cancer Study

One of the studies looked at testicular cancer. Using the Surveillance, Epidemiology and End Results (SEER) database, lead author Sarah C. Markt, ScD, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, and colleagues identified 10,211 men diagnosed with testicular germ cell tumors (GCTs) between 2007 and 2011.

Results showed that men with no insurance and men covered by Medicaid were 26% and 62% more likely, respectively, to have metastatic disease at the time of diagnosis than men who had insurance. Metastatic disease was defined as stage II or stage III testicular GCTs.

The uninsured and Medicaid recipients were also 39% and 22% more likely, respectively, to present with intermediate- to poor-risk disease than their insured counterparts and were approximately one third more likely to present with larger tumors as well.

Table. Insurance Status and Disease Presentation at Diagnosis in Men With Testicular Cancer

Variable Insured Any Medicaid (Relative Risk) P Value Uninsured (Relative Risk) P Value
Metastatic disease Reference 1.62 <.001 1.26 <.001
Intermediate-/poor-risk disease Reference 1.39 <.001 1.22 0.01
Tumor ≥4 cm Reference 1.32 <.001 1.36 <.001


Over 95% of all men in the cohort underwent radical orchiectomy.

But men with no insurance diagnosed with stage I seminoma were 18% less likely to receive additional radiation after surgery compared with insured men, although no association was seen between receipt of radiation and Medicaid status.

On the other hand, both the uninsured and Medicaid recipients were approximately 25% less likely to undergo retroperitoneal lymph node dissection, an important part of GCT care and a metric of quality, the authors observe.

Most importantly, "uninsured men had a 58% increased risk of all-cause mortality and an 88% increased risk of GCT-specific mortality in comparison with men with insurance," Dr Markt and coauthors write.

Similarly, men insured under Medicaid had a 69% higher risk for all-cause mortality and a 51% greater risk for disease-specific mortality compared with men with insurance, they add. It is noteworthy that testicular GCTs are curable even when metastatic.

"Other studies have demonstrated that broad groups of patients with different cancers who are uninsured are more likely to present with metastatic disease, less likely to receive definitive treatment, and more likely to die of any cause in comparison with those with traditional insurance," note the author.

"[But] our study shows that these results are persistent even among Medicaid patients with higher curable GCTs," they add. "These results suggest that efforts to eliminate cancer disparities through the expansion of Medicaid alone may be insufficient."

Poorer Survival Odds for Glioblastoma

The other study looked at glioblastoma multiforme (GBM), the most common primary brain cancer in adults, and found that a lack of insurance and insurance coverage by Medicaid was associated with poorer survival odds.

Again, on the basis of an analysis of the SEER database, having no insurance or being covered by Medicaid alone emerged as independent predictors of a shorter lifespan in adults diagnosed with GBM compared with patients covered by non-Medicaid insurance.

Specifically, uninsured patients had a 14% greater likelihood of having a shorter survival time, while those treated under Medicaid had a 10% greater probability of having a shorter survival time compared with patients with insurance, differences between the groups that were statistically significant (P = .018 and .006, respectively).

Indeed, the only other independent predictor of a shorter survival after diagnosis was large tumor size, which was associated with a 26% greater likelihood of having a shorter survival compared with smaller tumors at presentation (P < .001).

Compared with being insured, being insured by Medicaid was associated with a 36% lower probability of undergoing surgery.

Medicaid insurance was also associated with a 38% lower probability of receiving adjuvant radiation, while the uninsured were 43% less like to receive adjuvant radiation compared with those who were insured.

"We also discovered a yearly improvement in the survival of patients with GBM in United States over 5 consecutive years during the study period (2007-2011)," note Xiaoming Rong, MD, Johns Hopkins University School of Medicine, Baltimore, Maryland, and colleagues.

However, when the group analyzed improvement in survival over these 5 years by insurance status, "the trend toward yearly progressive improvement in GBM survival occurred only in patients with non-Medicaid insurance," they add.

Quality of Treatment

"The most concerning findings from both studies were the differences in the quality of treatment," Dr Halpern and Dr Brawley observe in their commentary.

This is because both the uninsured and those covered by Medicaid were already in the healthcare system after their cancer diagnosis but they clearly received less-than-optimal care, the editorialists add.

Dr Halpern and Dr Brawley note that the Affordable Care Act does allow states to expand Medicaid coverage to certain individuals so that the uninsured at least should get better access to healthcare services.

However, simply providing insurance or access to healthcare will not completely reduce disparities in the care for the uninsured or underinsured, they argue.

For example, individuals who have no insurance may be uncomfortable navigating the healthcare system and might not appreciate the seriousness of early symptoms, thereby delaying their presentation even if they had direct access to medical care.

"There is also literature suggesting that the poor are more likely to have denial and fatalism once symptoms are recognized [and] this can influence the time to presentation and other medical decisions," the editorialists observe.

Thus, there is a need to focus on strategies and interventions that address disparities in healthcare, not just focus on the improved anticancer interventions.

"The provision of adequate care for all individuals diagnosed with cancer has the potential to save thousands of additional lives per year," Dr Halpern and Dr Brawley point out.

Dr Markt and Dr Rong have disclosed no relevant financial relationships. Coauthors on the Rong study have made disclosures, which are contained in the published document. Dr Halpern has served as a consultant for AbbVie.

Cancer. Published online August 8, 2016. Markt abstract Rong abstract Editorial

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