A few years ago, Joseph Shrager, MD, a lung cancer surgeon at Stanford School of Medicine, Stanford, California, noticed that an unusually large proportion of the patients he was operating on were exactly 65 years of age.
"There was no reason rates should differ much between the ages of 63 and 65," he reasoned, "so there had to be some explanation for this."
Shrager then asked his thoracic surgery colleagues whether they had noticed the same thing.
They had: their own divisional data showed a twofold increase in lung cancer surgeries for 65-year-olds compared to patients who were 64.
The investigators then turned to a national cancer database to see whether the same phenomenon was occurring nationally.
They found that there was an abrupt and significant increase in diagnoses of the four most common cancers (lung, colon, breast, and prostate) in US patients who were 65 years old in comparison with patients who were younger than 65, as well as those older than 65.
"Essentially we showed there is a big jump in cancer diagnoses as people turn 65 and are thus Medicare eligible," Shrager observed.
"This suggests that many people are delaying their care for financial reasons until they get health insurance through Medicare," he said.
Findings from the study were published online March 29 in Cancer.
For the study, the team turned to the Surveillance, Epidemiology, and End Results (SEER) Program, which collects data on cancer patients from 18 registries in the United States.
The team focused on individuals aged 60 to 69 years who were diagnosed with one of the four most common cancers in the United States. They found that 134,991 patients had been diagnosed with lung cancer; 175,558 with breast cancer; 62,721 with colon cancer; and 238,823 with prostate cancer.
They then divided these patients into two groups, those aged 61 to 64 years, who were not eligible for Medicare; and those aged 65 to 69 years, who were.
"For all four cancers, the AoA [age-over-age] growth in the number of cancer diagnoses was higher at the transition from 64 to 65 years old when compared to all other age transitions within the studied decade," the team reports.
For example, for persons aged 61 to 64 years, lung cancer diagnoses increased by approximately 3% to 4% per year.
"However, abruptly, at the age of 65, there was a greater than 2-fold increase in the AoA growth vs the prior year," the investigators report.
An "even more pronounced" trajectory was seen for colon cancer. For patients who were not yet eligible for Medicare, the annual growth rate in colon cancer diagnoses was 1% to 2% per year, but the growth rate abruptly increased by approximately sevenfold, to nearly 15%, at the age of 65.
A similar spike was seen in prostate cancer diagnoses at age 65 years. A smaller but still significant spike in breast cancer diagnoses in women occurred at the age of 65.
Conversely, "in the years following age 65, the proportional change was negative for all four cancers," the authors state — an indication that there was an absolute decrease in the incidence of new cancer diagnoses immediately after the age of 65, they add.
"[This suggests] that a 'backlog' of cancer diagnoses is made when patients become eligible for Medicare," the authors comment.
These findings support their hypothesis that patients are waiting to undergo cancer-related diagnostic and therapeutic interventions until they become eligible for Medicare. The authors warn that this delay could result in needless cancer-related deaths.
Insurance a "Disaster" for Many Americans
In an interview with Medscape Meical News, Shrager described the US health insurance system as an "incredible disaster" for many Americans.
"If you are well insured through an excellent job or if you are wealthy, healthcare is fantastic, but once you retire and you retire before the age of 65, then you have this period of time when you have no coverage unless you want to pay an extraordinary amount to get insurance on the open market," he explained.
Indeed, the authors note that from 13% to 25% of individuals aged 61 to 64 years are uninsured or that there is a gap in their medical coverage at some point before they become eligible for Medicare.
"There is also a particularly vulnerable period somewhere between the ages of 55 and 65 where a fair number of patients are uninsured, and this is also the age group where patients start getting a lot of cancers," Shrager noted.
"So I think you could probably have a significant impact on cancer mortality if you extended Medicare to a younger age group, and while maybe it's not 'Medicare-for-all,' at least it could be 'Medicare-extended-to-somewhat-younger-people,' " he added.
"I think this study is a very strong argument for at least reducing the age for Medicare coverage," he emphasized.
No Surprise at All
It's no surprise that people start to seek medical care when they become eligible for Medicare coverage, said Cary Gross, MD, professor of medicine, Yale School of Medicine, New Haven, Connecticut, who was approached for comment. He has seen this in his own medical practice, and he finds it "heartbreaking" when a patient has known there is something medically wrong with them for months or even years, but they were waiting for Medicare so as to avoid getting bills they knew they couldn't pay.
"There is no reason why people in the richest country on earth should have to choose between money for food or housing or electricity and health care," Gross told Medscape Medical News in an email.
"But these are the choices people are facing every day," he added.
Although the Affordable Care Act, which became law in 2010 during former President Barack Obama's administration, has dramatically cut the number of uninsured people, the "changes put in place during the prior [ie, Trump] administration reversed these trends," Gross noted, and the numbers of the uninsured are once again creeping up.
"There are over 30 million people under the age of 65 without insurance in the US, including nearly 15% of people between the ages of 18 to 64," he pointed out. To be uninsured in the United States today is more of a problem than ever, he suggested — "not only because of the pandemic, but the cost of healthcare has been rising at a much faster rate than the average income, putting healthcare further and further out of reach for the uninsured.
"This is an excellent study," he said. Although it is not clear whether all the newly diagnosed stage I cancers identified in the study would have caused health problems for patients, "this does not distract from the take-home point of the study, which is that the arbitrary age threshold of 65 years for universal healthcare must be reconsidered," he said.
"Everyone deserves health insurance, regardless of their age," Gross emphasized.
Stranger has disclosed no relevant financial relationships. Gross has received research grants from J&J, Genentech, and AstraZeneca unrelated to the current study.
Cancer. Published online March 29, 2021. Abstract
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Cite this: Cancer Diagnoses Jump at 65 Years When Medicare Kicks In - Medscape - Apr 07, 2021.