Medicaid or No Insurance Associated With Worse Cancer-Specific Survival in Nonelderly Patients


Key Points

  • Compared with patients with non-Medicaid insurance, patients with Medicaid or no insurance were significantly more likely to present with advanced disease and to not receive cancer-directed surgery or radiation therapy.
  • On adjusted analysis, risk of cancer-specific mortality was increased by 44% in Medicaid patients and 47% in uninsured patients.

In a study reported in the Journal of Clinical Oncology, Walker et al found that among nonelderly patients with the top 10 most lethal cancers, those with Medicaid or no insurance were more likely to present with advanced disease and less likely to receive cancer-directed surgery or radiation therapy and had significantly worse cancer-specific survival.

Study Details

The study involved data from 473,722 patients aged 18 to 64 years diagnosed with one of the top 10 deadliest cancers (breast, prostate, lung, colorectal, head and neck, liver, pancreatic, ovarian, and esophageal cancers and non-Hodgkin lymphoma) between January 2007 and December 2010 as identified from the public-use SEER (Surveillance, Epidemiology, and End Results) database.

In the cohort, 78.4% had non-Medicaid insurance, 11.6% had Medicaid coverage, 4.7% did not have insurance, and 5.2% had unknown insurance status. Lack of insurance was associated with younger age, male sex, nonwhite race, being unmarried, rural residence, and higher county poverty level. A total of 55.6% of the uninsured group were men; nonwhite patients accounted for 32.9% of the cohort, 46.3% of the uninsured group, and 50.9% of the Medicaid group; and single patients accounted for 34.3% of the cohort, 57.8% of the uninsured group, and 64.3% of the Medicaid group.

Stage and Treatment Differences

Patients with insurance other than Medicaid were less likely to present with distant disease (16.9%) vs those with Medicaid coverage (29.1%) or without insurance coverage (34.7%; P < .001) and more likely to present with localized disease (60.8% vs 42.2% and 40.3%; P < .001). Patients with non-Medicaid insurance were more likely to receive cancer-directed surgery or radiation therapy (79.6%) vs those with Medicaid (67.9%) or without insurance (62.1%; P < .001). The hazard ratios (HRs) for not receiving cancer-directed surgery/radiation therapy among Medicaid and uninsured patients were significant for each of the 10 cancers after controlling for   age, race, sex, marital status, residence (urban vsrural), and percent of county below federal poverty level.

Cancer-Specific Survival

Median follow-up was 17 months. Unadjusted 2-year cause-specific survival was 86.2% among patients with non-Medicaid insurance, 69.1% among those with Medicaid, and 66.5% among those without insurance (P< .001). In analysis adjusting for age, race, sex, marital status, residence, percent of county below federal poverty level, site, stage, and receipt of cancer-directed surgery/radiation therapy, both Medicaid patients (HR = 1.44, P < .001) and those with no insurance (HR = 1.47, P < .001) were at increased risk of cancer-specific death compared with patients with non-Medicaid insurance. Although increases in risk varied among the 10 cancers, hazard ratios always favored non-Medicaid insurance and all hazard ratios were significantly increased among Medicare patients and uninsured patients for all cancers except for ovarian cancer in uninsured patients.

The investigators concluded: “[L]ack of insurance is associated with advanced disease stage at presentation, less use of cancer-directed surgery and/or [radiation therapy], and worse survival among patients diagnosed with one of the 10 most deadly cancers in this large, population-based data set. Upcoming changes resulting in the expansion of private insurance and Medicaid will likely alter cancer care in the United States. Further research will be required to determine if and to what degree the presentation, treatment, and outcomes of cancer are affected.”

Usama Mahmood, MD, of The University of Texas MD Anderson Cancer Center, is the corresponding author for the Journal of Clinical Oncology article.

The study was supported by the Keck Center for Interdisciplinary Bioscience Training of the Gulf Coast Consortia. Benjamin D. Smith, MD, receives 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®.