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Are Racial/Ethnic Disparities in Breast Cancer Diagnosis Caused by Health Insurance Coverage?


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Lack of insurance coverage is a major cause of delayed breast cancer screening and treatment among minority women, which could lead to a decrease in a patient’s chance of survival. Nearly half of the disparity in later-stage diagnosis between non-Hispanic white women and black, Hispanic, and Asian/Pacific Islander women was mediated by being uninsured or underinsured, according to a new study published by Ko et al in JAMA Oncology.

Methods

More than 177,000 women aged 40 to 64 who were diagnosed with invasive stage I–III breast cancer between 2010 and 2016 were included in the study, which used data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results program.

This is the first study to use statistical mediation methods and a large cancer registry database to quantify the extent that adequate health insurance is a factor in the stage of breast cancer diagnosis among a diverse population of women in the United States.

“Patients diagnosed with breast cancer at a later stage typically require more intensive treatment and are at a higher risk for treatment-related morbidity and poorer overall quality of life, especially compared to those who receive chemotherapy. Diagnosing breast cancer early is not only beneficial for individual patients and families, but also on society as a whole to decrease medical costs and promote equity among all populations.”
— Naomi Y. Ko, MD, MPH, AM

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Results

Non-Hispanic white women were insured at a higher rate at the time of diagnosis compared with non-Hispanic black women, American Indian/Alaska Native, Asian/Pacific Islander, and Hispanic women, according to the report. A higher proportion of women who were either uninsured or receiving Medicaid received a diagnosis of locally advanced breast cancer vs women with health insurance—20% vs 11%, respectively. In multivariable models, women in minority groups were more likely to receive a diagnosis of stage III, or locally advanced, disease than non-Hispanic white women were. Overall, the researchers wrote, “nearly half (45%–47%) of racial differences in the risk of locally advanced disease were mediated by health insurance.”

“Diagnosing cancer at a later stage and lack of health insurance have negative consequences for patients and their families,” said lead study author Greory S. Calip, PharmD, MPH, PhD, in a statement. “Inadequate health insurance coverage also mediates the growing survivorship gap experienced by racial and ethnic minorities with cancer.”

Insurance is a modifiable risk factor, and “having adequate health insurance for all could reduce the persistent racial outcome disparities in breast cancer,” said first study author Naomi Y. Ko, MD, MPH, AM.

“Patients diagnosed with breast cancer at a later stage typically require more intensive treatment and are at a higher risk for treatment-related morbidity and poorer overall quality of life, especially compared to those who receive chemotherapy,” she said. “Diagnosing breast cancer early is not only beneficial for individual patients and families, but also on society as a whole to decrease medical costs and promote equity among all populations.”

Disclosure: The study was funded by the National Institutes of Health, National Center for Advancing Translational Sciences, National Cancer Institute, and National Institute on Minority Health and Health Disparities. For full disclosures of the study authors, visit jamanetwork.com.

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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