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Uninsured Young Adults Have Poorer Cancer-Specific Outcomes

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Key Points

  • Uninsured patients are more likely to present with metastatic disease.
  • Uninsured patients are less likely to receive definitive treatment and have higher all-cause mortality.

The Patient Protection and Affordable Care Act is likely to improve insurance coverage for young adults. In a study reported in the Journal of Clinical Oncology, Aizer et al examined the association between insurance status and cancer outcomes among young adults, finding that the uninsured have higher rates of presentation with metastatic disease and all-cause mortality and lower rates of definitive treatment.

Study Details

The study involved data from 39,447 Surveillance, Epidemiology, and End Results (SEER) program patients aged 20 to 40 years diagnosed with a malignant neoplasm between 2007 and 2009. The association between insurance status and disease stage at presentation, use of definitive therapy, and all-cause mortality was assessed.

Factors Associated With Uninsured Status

Among 36,869 insured and 2,578 uninsured patients, the uninsured were (all P <. 001) younger (median, 33 vs 35 years), less educated (79% vs 82% with high school education), poorer (median household income, $46,000 vs $49,000), more likely to be male (50% vs 33%), more likely to be African American (14% vs 10%) and Hispanic (36% vs 19%) and less likely to be white (45% vs 62%) and Asian (4% vs 9%), more likely to be unmarried (67% vs 43%), and more likely to have a rural residence (14% vs 9%).

Disease sites also differed (P < .001), with the uninsured more likely to have, for example, male genital (17% vs 9%), female genital (15% vs 11%), and gastrointestinal (13% vs 9%) cancers and lymphoma (17% vs 12%) and less likely to have breast (10% vs 21%), skin (6% vs 9%), and thyroid (10% vs 19%) cancers.

Increased Risk of Presentation With Metastases

In total, 18.5% of uninsured patients vs 11.3% of insured patients presented with metastatic disease; the difference was significant on multivariate analysis adjusting for age, median household income, education status, race, marital status, population density, and site of primary malignancy (odds ratio [OR] = 0.84, P = .003, for insured vs uninsured). Other factors associated with reduced risk for presentation with metastatic disease on multivariate analysis consisted of higher education level, female sex, white vs African American and Hispanic race, and being married.

Reduced Use of Definitive Treatment

On multivariate analysis adjusting for demographic factors, type of primary malignancy, and disease stage, insured patients were significantly more likely to receive definitive therapy (OR = 1.95, P < .001). Other factors associated with reduced likelihood of receiving definitive treatment were African American, Hispanic, or Asian vs white race and stage III vs I disease.

Higher All-Cause Mortality

On multivariate analysis adjusting for demographic factors, disease stage, and receipt of definitive treatment, insured patients had significantly reduced risk of all-cause mortality (hazard ratio [HR] = 0.77, P = .002). Other significant predictors of lower all-cause mortality were female sex, white vs African American race, being married, disease stage I vs II and III, and receipt of definitive treatment.

Interaction models showed no significant difference for men vs women with regard to insurance status and stage at presentation (P = .32 for interaction) or all-cause mortality (P = .91), with the effect of insurance status on receipt of definitive treatment being significantly stronger in women (P = .02).

The investigators concluded, “The improved coverage fostered by the [Affordable Care Act] may translate into better outcomes among most young adults with cancer. Extra consideration will need to be given to ensure that patients who will face premium increases in the individual market can obtain insurance coverage under the [Affordable Care Act].”

Ayal A. Aizer, MD, MHS, of the Harvard Radiation Oncology Program, is the corresponding author for the Journal of Clinical Oncology article.

The study was supported by Heritage Medical Research Institute/Prostate Cancer Foundation, Joint Center for Radiation Therapy Foundation, Fitz’s Cancer Warriors, David and Cynthia Chapin, and a grant from an anonymous family foundation. Study author Benjamin Falit, MD, reported a consultant or advisory role with CVS Caremark. Paul L. Nguyen, MD, reported a consultant or advisory role with Ferring Pharmaceuticals, Astellas Pharma, and Medivation, and research funding from Varian Medical Systems.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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