The impact of health insurance status on the stage of cervical cancer diagnosis at a tertiary care center in Massachusetts

Health insurance in the United States: A case of effectively maintained inequality?

The theory of Effectively Maintained Inequality (EMI) (Lucas, 2001) posits that goods have both quantitative (how much?) and qualitative (what kind?) dimensions. Coupled with the hypothesized mechanisms of EMI, this simple observation greatly complicates research and policy development concerning inequality. First applied to explain educational inequality in the United States, evidence for the theory has been found in education systems in over 20 countries, including Chile, China, the Czech Republic, Denmark, Egypt, Germany, Greece, Ireland, Nigeria, South Africa, and South Korea. Yet, while EMI was proposed as a general theory of inequality, to date no research has assessed its applicability to domains outside education. This work uses nearly two decades of National Health Interview Survey data (N = 451,161) to provide the first effort to assess whether EMI illuminates patterns of inequality outside education, by taking up the issue of health insurance in the United States.

Mediation of Racial and Ethnic Inequities in the Diagnosis of Advanced-Stage Cervical Cancer by Insurance Status

Importance

Black and Hispanic or Latina women are more likely than White women to receive a diagnosis of and to die of cervical cancer. Health insurance coverage is associated with diagnosis at an earlier stage of cervical cancer.

Objective

To evaluate the extent to which racial and ethnic differences in the diagnosis of advanced-stage cervical cancer are mediated by insurance status.

Design, Setting, and Participants

This retrospective, cross-sectional population-based study used data from the Surveillance, Epidemiology, and End Results (SEER) program on an analytic cohort of 23 942 women aged 21 to 64 years who received a diagnosis of cervical cancer between January 1, 2007, and December 31, 2016. Statistical analysis was performed from February 24, 2022, to January 18, 2023.

Exposures

Health inusurance status (private or Medicare insurance vs Medicaid or uninsured).

Main Outcomes and Measures

The primary outcome was a diagnosis of advanced-stage cervical cancer (regional or distant stage). Mediation analyses were performed to assess the proportion of observed racial and ethnic differences in the stage at diagnosis that were mediated by health insurance status.

Results

A total of 23 942 women (median age at diagnosis, 45 years [IQR, 37-54 years]; 12.9% were Black, 24.5% were Hispanic or Latina, and 52.9% were White) were included in the study. A total of 59.4% of the cohort had private or Medicare insurance. Compared with White women, patients of all other racial and ethnic groups had a lower proportion with a diagnosis of early-stage cervical cancer (localized) (American Indian or Alaska Native, 48.7%; Asian or Pacific Islander, 49.9%; Black, 41.7%; Hispanic or Latina, 51.6%; and White, 53.3%). A larger proportion of women with private or Medicare insurance compared with women with Medicaid or uninsured received a diagnosis of an early-stage cancer (57.8% [8082 of 13 964] vs 41.1% [3916 of 9528]). In models adjusting for age, year of diagnosis, histologic type, area-level socioeconomic status, and insurance status, Black women had higher odds of receiving a diagnosis of advanced-stage cervical cancer compared with White women (odds ratio, 1.18 [95% CI, 1.08-1.29]). Health insurance was associated with mediation of more than half (ranging from 51.3% [95% CI, 51.0%-51.6%] for Black women to 55.1% [95% CI, 53.9%-56.3%] for Hispanic or Latina women) the racial and ethnic inequities in the diagnosis of advanced-stage cervical cancer across all racial and ethnic minority groups compared with White women.

Conclusions and Relevance

This cross-sectional study of SEER data suggests that insurance status was a substantial mediator of racial and ethnic inequities in advanced-stage cervical cancer diagnoses. Expanding access to care and improving the quality of services rendered for uninsured patients and those covered by Medicaid may mitigate the known inequities in cervical cancer diagnosis and related outcomes.

Screening History and Survival Among Women With Cervical Cancer in Puerto Rico

OBJECTIVES

Cervical cancer incidence is rising in Puerto Rico (PR). Screening for cervical cancer could prevent the occurrence of the disease or lead to its early detection, translating to survival benefits. In this study, we evaluated the association of cervical cancer screening status with tumor diagnosis and survival among Hispanic women living in PR.

METHODS

We analyzed data for 506 incident cases of primary cervical cancer diagnosed from the period 2011-2014, identified through the PR Central Cancer Registry. We ascertained screening status 3 years before cervical cancer diagnosis using data from the period 2008-2014 from the PR Central Cancer Registry-Health Insurance Linkage Database. Patients were followed until 2019. Our outcomes of interest were stage at diagnosis and survival.

RESULTS

Most women (78.86%) were covered by public insurance (Medicare and/or Medicaid), and 69.57% underwent screening 3 years before their diagnosis. The proportion of cases diagnosed with localized stage was significantly greater among the screened group compared with those unscreened (43.5% vs 33.1%, p < .0001). Multivariate analysis showed that women insured through Medicaid were less likely to have been screened when compared with women with private insurance (odds ratio = 0.29; 95% CI = 0.16-0.52). Five-year survival was significantly greater among screened (72%) than unscreened (54%) women (p log-rank < 0.05). The multivariate Cox proportional hazards model showed that women who received screening had a 39% (hazard ratio [HR] = 0.61; 95% CI = 0.43-0.87) lower risk of death compared with unscreened women.

CONCLUSION

Our findings exemplify survival benefits among women who underwent cervical cancer screening in PR. Interventions to improve screening uptake and adherence are a public health priority.

Influence of Sociodemographic Determinants on the Hodgkin Lymphoma Baseline Characteristics in Long Survivors Patients Enrolled in the Prospective Phase 3 Trial AHL2011

INTRODUCTION

Whereas numerous studies on several cancers describe the link between social conditions and disease severity, little is known about the social and demographic characteristics of Hodgkin lymphoma (HL) patients. At diagnosis, 10-15% of the patients in the advanced stages have a well-known poor outcome owing to their chemoresistance, but the determinants of the more advanced stages remain elusive. The objective of the present study was to decipher the potential impact of social disparities on the disease features at diagnosis and analyze how the sociodemographic patient features could impact the HL outcome of patients with advanced-stage HL enrolled in the AHL2011 trial.

METHODS

This ancillary study was conducted on a cohort of patients from French centers that had recruited more than five patients in the phase III AHL2011 study (NCT0135874). Patients had to be alive at the time of the ancillary study and had to have given their consent to answer the questionnaire. Pre-treatment data (age, gender, stage, B symptoms, IPS), the treatment received, the responses to PET-CT, and the presence of serious adverse events (serious adverse events-SAEs) were all extracted from the AHL2011 trial database. Sociodemographic data-marital status, living area, level of education, socio-professional category, and professional situation-were extracted from the questionnaires. The population density at the point of diagnosis was determined based on ZIP Code, and the distance from the reference medical center was then calculated by the road network. Baseline PET acquisition was performed before any treatment. PET images at baseline were centrally reviewed. The total metabolic tumor volume (TMTV) at the baseline was calculated using a 41% SUVmax cutoff for each lesion. Progression-free survival was defined as the time from randomization to the first progression, relapse, or death from any cause or the last follow-up. The data cutoff for the analyses presented here was 31 October 2017. The progression-free survival was analyzed on an intention-to-treat basis.

RESULTS

Among the 823 patients enrolled in the AHL2011 study, the questionnaire was sent to 394 patients, of whom 232 (58.9%) responded. At the time of HL diagnosis, 61.9% (N = 143) of patients declared that they were not socially isolated, 38.1% (N = 88) that they were single, 163 (71.2%) had a professional activity, and 66 (28.8%) were inactive owing to unemployment, retirement, or sick leave. Of the patients, 31.1% (N = 71) lived in a rural region, compared to 68.9% (N = 157) that lived in an urban region. The residence ZIP Code at the time of HL diagnosis was available for 163 (70%). Sociodemographic characteristics did not influence the presence of usual prognostic factors (ECOG, B symptoms, bulky mass, IPS) except for professional activity, which was associated with more frequent low IPS (0-2) (79 (48.5%) active versus 20 (30.3%) inactive patients; p = 0.012). Likewise, no correlation was observed between TMTV and sociodemographic characteristics. However, the TMTV quartile distribution was different according to the living area, with the two upper quartiles being enriched with patients living in a rural area (p = 0.008). Moreover, a negative correlation between the average number of the living area's inhabitants and TMTV (R Pearson = -0.29, p = 0.0004) was observed.

CONCLUSION

This study focused on sociodemographic parameters in advanced-stage HL patients and shows that professional activity is associated with more favorable disease features (low IPS), while patients living in rural or low-populated areas are more likely to have an unfavorable HL presentation with a high tumor burden (high TMTV). These data suggest that some patient sociodemographic characteristics might impact either access to medical care or environmental exposure, leading to a higher frequency of unfavorable presentations. Further prospective sociodemographic studies are necessary to confirm these preliminary results.

Impact of prior underinsurance on cervical cancer screening among Davidson County, Tennessee, women diagnosed with invasive cervical cancer, 2008-2018

INTRODUCTION

We sought to investigate the association between insurance coverage history and cervical cancer screening among Davidson County, Tennessee, women diagnosed with incident cervical cancer.

METHODS

We reviewed medical records of women diagnosed with invasive cervical cancer from 2008 through 2018 identified via the state's cancer registry and by active surveillance of diagnostic pathology reports for the HPV-IMPACT project. Per 2012 United States Preventive Services Task Force recommended cervical cancer screening guidelines, women were characterized into three screening history categories: "no screening", "no follow-up" and "test/screening failure". Multivariable logistic regression measured the association of prior inadequate insurance (underinsurance) and screening history ("no screening/no follow-up" compared to "test/screening failure").

RESULTS

Of 212 women, most (77%) had not undergone recommended cervical cancer screening or follow-up prior to cancer diagnosis. Overall, 28% of women had history of underinsurance in 5 years prior to diagnosis. In adjusted analyses, underinsured women were more likely to have a "no screening/no follow-up" prior to cancer diagnosis (aOR 4.26; 95% CI 1.15-15.80) compared to "test/screening failure" history. Non-white race (aOR 2.73; 95% CI 0.98-7.61), older age (aOR 1.03 per year; 95% CI 1.00-1.07), and history of smoking (aOR 4.07; 95% CI 1.54-10.74) were also associated with increased likelihood of "no screening/no follow-up".

CONCLUSIONS

Previous underinsurance was independently associated with non-adherence to cervical cancer screening and follow-up guidelines among women with incident cervical cancer. Further study of factors contributing to inadequate cervical cancer screening and interventions to increase cervical cancer screening in high-risk populations is needed.

Trends in Patient Demographics and Diagnostic Yield at an Academic Colposcopy Clinic From 2008 to 2018

OBJECTIVE

The aim of the study was to review trends in colposcopy rates and diagnoses of high-grade dysplasia and cancer for the past 10 years at an academic colposcopy clinic.

MATERIALS AND METHODS

A registry of patients seen January 2008 to December 2018 at an academic colposcopy clinic was queried to examine trends in patient characteristics, cytology and histology results, and interventions during the study period, which coincided with the implementation of revised national guidelines. Differences in characteristics were examined with analysis of variance and χ tests. Trends in diagnoses were examined with logistic regression. Trends in interventions were modeled with binomial distribution, logit link, Poisson distribution, and log link.

RESULTS

Among 5,103 women referred for abnormal pap testing, human papillomavirus, or dysplasia, the mean age increased over time (30.6 in 2008 to 38.4 in 2018, p < .0001) and fewer pregnant patients were served (11.3% in 2008 vs 2.8% in 2018, p < .0001). There were decreased rates of low-grade cytology (81.3% in 2008 vs 73.6% in 2018, p = .006) and increased rates of human papillomavirus positivity (4.1% in 2008 vs. 14.4% in 2018, p < .0001) on referral. Fewer colposcopies were performed per patient per year (1.2 in 2008 vs. 0.7 in 2018, p < .0001), and with this targeted intervention, there was an increased percentage of patients diagnosed with high-grade histology over time (adjusted p = .05).

CONCLUSIONS

Over time, the number of colposcopies performed per patient decreased, especially in younger and pregnant women. Meanwhile, the percentage of patients diagnosed with high-grade histology increased, suggesting that guidelines decreased unnecessary procedures while increasing the percentage of patients diagnosed with precancerous lesions.

Impact of Insurance Status on Diagnostic Stage in Hodgkin's Lymphoma in the United States: Implications for Detection and Outcomes

Introduction and objective

Hodgkin’s lymphoma (HL) is a form of cancer originating from white blood cells that presents upon diagnosis with well-characterized symptoms (palpable lymph nodes, fever, night sweats, weight loss). HL is currently one of the most treatable cancers, with a successful treatment rate of 75% worldwide. The objective of this study is to evaluate the association between insurance status and the stage of diagnosis of HL in the United States from the years 2007 to 2016.

Methods

A cross-sectional study using secondary data from the Surveillance, Epidemiology, and End Results (SEER) program database was used. Insurance status of each patient was defined as uninsured (not insured or self-pay), any Medicaid (includes Indian/public health service), insured (private insurance, managed care, Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), or Medicare) and insured not specified. Staging was dictated via the SEER combined/American Joint Committee on Cancer (AJCC) cancer staging guidelines. We divided the stages into early-stage (localized) and late-stage (regional by direct extension, involving distant sites/nodes). We used univariate descriptive analysis to determine baseline characteristics, bivariate analysis to evaluate potential confounding, and binary logistic regression to compute unadjusted and adjusted odd ratios and corresponding 95% confidence intervals. 

Results 

Approximately 77% of insured individuals presented with a late-stage diagnosis, compared with 78.1% for insured not specified, 82% for any Medicaid, and 84.9% for uninsured. After adjusting for age, sex, race and marital status, insurance status had a significant impact on the stage of diagnosis of Hodgkin's lymphoma. The odds ratio (OR) for advanced stage diagnosis of HL in uninsured patients compared to insured patients was 1.72 (95% CI 1.03-2.86, p=0.037); for any Medicaid, the OR was 1.37 (95% CI 1.02-1.83, p=0.036), and for insured not specified, 1.09 (95% CI 0.83-1.44, p=0.522).

Conclusions

Uninsured patients are significantly more likely to have a later stage diagnosis of HL compared to those that are insured. The findings of this study coincide with the associations found in previous studies involving other cancers such as breast, cervical, prostate, colorectal, hepatocellular, bladder and kidney cancers outcomes and insurance status. 

MEG3 Induces Cervical Carcinoma Cells' Apoptosis Through Endoplasmic Reticulum Stress by miR-7-5p/STC1 Axis

Background: Many patients with advanced cervical cancer (CC) have a poor prognosis and their mortality rank the first among women with malignant tumors. It's essential to explore the molecular mechanism of CC in clinical practice. Long noncoding RNA maternally expressed gene 3 (MEG3) has been reported to downregulate in CC tissues. However, the underlying mechanism of MEG3 in CC remains poorly elaborated. The current study aimed to explore the potential mechanism of MEG3 inducing endoplasmic reticulum stress (ERs)-mediated apoptosis of CC cells. Methods: The expression of MEG3 and miR-7-5p in CC tissues and cell lines was verified by quantitative reverse transcription/polymerase chain reaction (qRT-PCR). The vector of MEG3, miR-7-5p inhibitor, and sh-SCT1 were transfected into CC cell lines, and their expression was tested by qRT-PCR. Flow cytometry was used to detect apoptosis, and ERs-related protein expression was performed by Western blot. The regulatory relationship between MEG3/SCT1 and miR-7-5p was validated by Dual luciferase reporter assay. Results: CC tissues and cell lines showed downregulated MEG3 and STC1, and upregulated miR-7-5p. Overexpression of MEG3 or miR-7-5p inhibition induced ERs-triggered apoptosis of CC cells. In addition, sh-STC1 can reverse the effects of overexpressing MEG3 on CC cell apoptosis. In addition, dual luciferase reporter assay revealed that miR-7-5p can directly target to MEG3 and STC1. Conclusion: MEG3, act as a competing endogenous RNA of miR-7-5p, accelerates ERs-mediated apoptosis of CC cells through regulating SCT1 expression.