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Wadhwa A, Roscoe C, Duran EA, Kwan L, Haroldsen CL, Shelton JB, Cullen J, Knudsen BS, Rettig MB, Pyarajan S, Nickols NG, Maxwell KN, Yamoah K, Rose BS, Rebbeck TR, Iyer HS, Garraway IP. Neighborhood Deprivation, Race and Ethnicity, and Prostate Cancer Outcomes Across California Health Care Systems. JAMA Netw Open 2024; 7:e242852. [PMID: 38502125 PMCID: PMC10951732 DOI: 10.1001/jamanetworkopen.2024.2852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 01/25/2024] [Indexed: 03/20/2024] Open
Abstract
Importance Non-Hispanic Black (hereafter, Black) individuals experience worse prostate cancer outcomes due to socioeconomic and racial inequities of access to care. Few studies have empirically evaluated these disparities across different health care systems. Objective To describe the racial and ethnic and neighborhood socioeconomic status (nSES) disparities among residents of the same communities who receive prostate cancer care in the US Department of Veterans Affairs (VA) health care system vs other settings. Design, Setting, and Participants This cohort study obtained data from the VA Central Cancer Registry for veterans with prostate cancer who received care within the VA Greater Los Angeles Healthcare System (VA cohort) and from the California Cancer Registry (CCR) for nonveterans who received care outside the VA setting (CCR cohort). The cohorts consisted of all males with incident prostate cancer who were living within the same US Census tracts. These individuals received care between 2000 and 2018 and were followed up until death from any cause or censoring on December 31, 2018. Data analyses were conducted between September 2022 and December 2023. Exposures Health care setting, self-identified race and ethnicity (SIRE), and nSES. Main Outcomes and Measures The primary outcome was all-cause mortality (ACM). Cox proportional hazards regression models were used to estimate hazard ratios for associations of SIRE and nSES with prostate cancer outcomes in the VA and CCR cohorts. Results Included in the analysis were 49 461 males with prostate cancer. Of these, 1881 males were in the VA cohort (mean [SD] age, 65.3 [7.7] years; 833 Black individuals [44.3%], 694 non-Hispanic White [hereafter, White] individuals [36.9%], and 354 individuals [18.8%] of other or unknown race). A total of 47 580 individuals were in the CCR cohort (mean [SD] age, 67.0 [9.6] years; 8183 Black individuals [17.2%], 26 206 White individuals [55.1%], and 13 191 individuals [27.8%] of other or unknown race). In the VA cohort, there were no racial disparities observed for metastasis, ACM, or prostate cancer-specific mortality (PCSM). However, in the CCR cohort, the racial disparities were observed for metastasis (adjusted odds ratio [AOR], 1.36; 95% CI, 1.22-1.52), ACM (adjusted hazard ratio [AHR], 1.13; 95% CI, 1.04-1.24), and PCSM (AHR, 1.15; 95% CI, 1.05-1.25). Heterogeneity was observed for the racial disparity in ACM in the VA vs CCR cohorts (AHR, 0.90 [95% CI, 0.76-1.06] vs 1.13 [95% CI, 1.04-1.24]; P = .01). No evidence of nSES disparities was observed for any prostate cancer outcomes in the VA cohort. However, in the CCR cohort, heterogeneity was observed for nSES disparities with ACM (AHR, 0.82; 95% CI, 0.80-0.84; P = .002) and PCSM (AHR, 0.86; 95% CI, 0.82-0.89; P = .007). Conclusions and Relevance Results of this study suggest that racial and nSES disparities were wider among patients seeking care outside of the VA health care system. Health systems-related interventions that address access barriers may mitigate racial and socioeconomic disparities in prostate cancer.
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Affiliation(s)
- Ananta Wadhwa
- Department of Surgical and Perioperative Care, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
| | - Charlotte Roscoe
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Elizabeth A. Duran
- VA San Diego Healthcare System, San Diego, California
- Department of Radiation Oncology, University of California, San Diego, San Diego
- Center for Health Equity Education and Research, University of California, San Diego, La Jolla
| | - Lorna Kwan
- Department of Surgical and Perioperative Care, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Urology, David Geffen School of Medicine at UCLA (University of California, Los Angeles), Los Angeles
| | - Candace L. Haroldsen
- Department of Surgical and Perioperative Care, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City
- IDEAS Center (COIN), VA Salt Lake City Healthcare System, Salt Lake City, Utah
| | - Jeremy B. Shelton
- Department of Surgical and Perioperative Care, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
| | - Jennifer Cullen
- Department of Population and Quantitative Health Sciences, Case Western Reserve, Cleveland, Ohio
| | - Beatrice S. Knudsen
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City
- IDEAS Center (COIN), VA Salt Lake City Healthcare System, Salt Lake City, Utah
| | - Mathew B. Rettig
- Department of Surgical and Perioperative Care, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Urology, David Geffen School of Medicine at UCLA (University of California, Los Angeles), Los Angeles
- Department of Medicine, Division of Hematology-Oncology, David Geffen School of Medicine at UCLA, Los Angeles
- UCLA Jonsson Comprehensive Cancer Center, Los Angeles
| | | | - Nicholas G. Nickols
- Department of Surgical and Perioperative Care, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Urology, David Geffen School of Medicine at UCLA (University of California, Los Angeles), Los Angeles
- UCLA Jonsson Comprehensive Cancer Center, Los Angeles
| | - Kara N. Maxwell
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Department of Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Kosj Yamoah
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- James A. Haley Veterans Hospital, Tampa, Florida
| | - Brent S. Rose
- VA San Diego Healthcare System, San Diego, California
- Department of Radiation Oncology, University of California, San Diego, San Diego
- Center for Health Equity Education and Research, University of California, San Diego, La Jolla
| | - Timothy R. Rebbeck
- VA Boston Healthcare System, Boston, Massachusetts
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hari S. Iyer
- Section of Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick
| | - Isla P. Garraway
- Department of Surgical and Perioperative Care, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Urology, David Geffen School of Medicine at UCLA (University of California, Los Angeles), Los Angeles
- UCLA Jonsson Comprehensive Cancer Center, Los Angeles
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Gupta A, Wilson LE, Pinheiro LC, Herring AH, Brown T, Howard VJ, Akinyemiju TF. Association of educational attainment with cancer mortality in a national cohort study of black and white adults: A mediation analysis. SSM Popul Health 2023; 24:101546. [PMID: 37954012 PMCID: PMC10637994 DOI: 10.1016/j.ssmph.2023.101546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/29/2023] [Accepted: 10/25/2023] [Indexed: 11/14/2023] Open
Abstract
Background Low educational attainment is associated with excess cancer mortality. However, the mechanisms driving this association remain unknown. Methods Using data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, we evaluated the associations of participant and parental/caregiver education with cancer mortality using Cox proportional hazards models, adjusting for socio-demographic characteristics and health conditions. We used principal components analysis to generate indices of measures representing the social determinants of health (SDOH) and health behaviors. We used structural equation modeling to determine if the association between educational attainment and cancer mortality was mediated by these domains. Results Among 30,177 REGARDS participants included in this analysis, 3798 (12.6%) had less than a high school degree. In fully adjusted models, those without a high school education experienced about 50% greater risk of death than high school graduates and higher (White participants HR: 1.47; 95% CI: 1.23, 1.76 and Black HR: 1.54; 95% CI: 1.33, 1.79). There was evidence of a modest mediation effect for the association between education and cancer mortality by the SDOH domain score (White total effect HR: 1.25; 95% CI: 1.18, 1.33, indirect effect HR: 1.04; 95% CI: 1.03, 1.05, direct effect HR: 1.21; 95% CI: 1.14, 1.28 and Black total effect HR: 1.24; 95% CI: 1.18, 1.29, indirect effect HR: 1.04; 95% CI: 1.03, 1.05, direct effect HR: 1.19; 95% CI: 1.14, 1.24). There was no evidence of mediation by the health behaviors score. No significant associations were found for female caregiver/mother's or male caregiver/father's education (N = 13,209). Conclusions In conclusion, participant education was strongly associated with cancer mortality, and this association was partially mediated by the SDOH domain score.
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Affiliation(s)
- Anjali Gupta
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Stanford University School of Medicine, Stanford, CA, USA
| | - Lauren E. Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | | | - Amy H. Herring
- Department of Statistical Science, Global Health, Biostatistics & Bioinformatics, Duke University, Durham, NC, USA
| | - Tyson Brown
- Department of Sociology, Duke University, Durham, NC, USA
| | - Virginia J. Howard
- Department of Epidemiology, University of Alabama at Birmingham, School of Public Health, Birmingham, AL, USA
| | - Tomi F. Akinyemiju
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
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3
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Duma N, Evans N, Mitchell E. Disparities in lung cancer. J Natl Med Assoc 2023; 115:S46-S53. [PMID: 37202003 DOI: 10.1016/j.jnma.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 02/01/2023] [Indexed: 05/20/2023]
Abstract
Lung cancer is the second most common cancer and the leading cause of cancer death among men and women in the United States. Despite a substantial decline in lung cancer incidence and mortality across all races in the last few decades, medically underserved racial and ethnic minority populations continue to carry the greatest burden of disease throughout the lung cancer continuum. Black individuals experience a higher incidence of lung cancer due to lower rates of low-dose computed tomography screening, which translate into advanced disease stage at diagnosis and poorer survival outcomes compared with White individuals. With respect to treatment, Black patients are less likely to receive gold standard surgery, have access to biomarker testing or high-quality treatment compared with White patients. The reasons for those disparities are multifactorial and include socioeconomic (eg, poverty, lack of health insurance, and inadequate education), and geographic inequalities. The objective of this article is to review the sources of racial and ethnic disparities in lung cancer, and to propose recommendations to help address them.
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Affiliation(s)
| | | | - Edith Mitchell
- Sidney Kimmel Cancer Center at Jefferson Health, Philadelphia, PA, USA.
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Xu B, Shi J, Lu W, Wu Y, Dong X. Elderly Pancreatic Adenocarcinoma Cancer Patients Could Benefit From Postoperative Chemotherapy. Pancreas 2023; 52:e37-e44. [PMID: 37165831 PMCID: PMC10317297 DOI: 10.1097/mpa.0000000000002214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/15/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVES The study aim to investigate whether elderly patients with resectable pancreatic ductal adenocarcinoma (PDAC) could benefit from postoperative chemotherapy. METHODS This study selects the data of PDAC patients who were diagnosed between 2004 and 2014 from the Surveillance, Epidemiology, and End Results program. Median overall survival (mOS) is determined by Kaplan-Meier survival curves. Multivariate logistic regression analysis and hazard ratio are employed to assess the association among potential prognostic factors. Propensity score matching evaluation is used to reduce bias. RESULTS In total, there are 11,865 PDAC patients selected from the Surveillance, Epidemiology, and End Results database. Elderly PDAC patients have poor prognoses compared with younger (mOS, 15 vs 21 months). The possible reason might be that the elderly patients are less likely to receive postoperative chemotherapy. After propensity score matching, it is found that, for those who receive postoperative chemotherapy, although the mOS of older group is not as good as that of the younger group (mOS, 20 vs 23 months; 18-month survival rate: 53.4% vs 61.3%), the mOS of older group prolonged by postoperative chemotherapy is similar to that of younger group (9 vs 9 months). CONCLUSIONS Elderly PDAC patients (≥70 years) might benefit from the currently used postoperative chemotherapy regimens.
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Affiliation(s)
- Bin Xu
- From the Department of Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jinbo Shi
- From the Department of Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Wenjie Lu
- From the Department of Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yulian Wu
- From the Department of Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xin Dong
- From the Department of Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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5
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Zamorano AS, Mazul AL, Marx C, Mullen MM, Greenwade M, Stewart Massad L, McCourt CK, Hagemann AR, Thaker PH, Fuh KC, Powell MA, Mutch DG, Khabele D, Kuroki LM. Community access to primary care is an important geographic disparity among ovarian cancer patients undergoing cytoreductive surgery. Gynecol Oncol Rep 2022; 44:101075. [PMID: 36217326 PMCID: PMC9547182 DOI: 10.1016/j.gore.2022.101075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 09/26/2022] [Accepted: 09/29/2022] [Indexed: 10/30/2022] Open
Abstract
Objective Given the importance of understanding neighborhood context and geographic access to care on individual health outcomes, we sought to investigate the association of community primary care (PC) access on postoperative outcomes and survival in ovarian cancer patients. Methods This was a retrospective cohort study of Stage III-IV ovarian cancer patients who underwent surgery at a single academic, tertiary care hospital between 2012 and 2015. PC access was determined using a Health Resources and Services Administration designation. Outcomes included 30-day surgical and medical complications, extended hospital stay, ICU admission, hospital readmission, progression-free and overall survival. Descriptive statistics and chi-squared analyses were used to analyze differences between patients from PC-shortage vs not PC-shortage areas. Results Among 217 ovarian cancer patients, 54.4 % lived in PC-shortage areas. They were more likely to have Medicaid or no insurance and live in rural areas with higher poverty rates, significantly further from the treating cancer center and its affiliated hospital. Nevertheless, 49.2 % of patients from PC-shortage areas lived in urban communities. Residing in a PC-shortage area was not associated with increased surgical or medical complications, ICU admission, or hospital readmission, but was linked to more frequent prolonged hospitalization (26.3 % vs 14.1 %, p = 0.04). PC-shortage did not impact progression-free or overall survival. Conclusions Patients from PC-shortage areas may require longer inpatient perioperative care in order to achieve the same 30-day postoperative outcomes as patients who live in non-PC shortage areas. Community access to PC is a critical factor to better understanding and reducing disparities among ovarian cancer patients.
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Affiliation(s)
- Abigail S. Zamorano
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States,Corresponding author.
| | - Angela L. Mazul
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Christine Marx
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Mary M. Mullen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Molly Greenwade
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - L. Stewart Massad
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Carolyn K. McCourt
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Andrea R. Hagemann
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Premal H. Thaker
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Katherine C. Fuh
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Matthew A. Powell
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - David G. Mutch
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Dineo Khabele
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Lindsay M. Kuroki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
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6
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Frego N, Alkhatib K, Labban M, Koelker M, Lughezzani G, Osman NY, Solomon SR, Lipsitz SR, Trinh QD, Cole AP. Association Between Alcohol Intake and Prostate Specific Antigen Screening: Results From a National Behavioral Survey. Urology 2022; 167:115-120. [PMID: 35772485 DOI: 10.1016/j.urology.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/10/2022] [Accepted: 06/08/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To assess the association between self-reported alcohol use and prostate cancer (PCa) screening using the U.S.-based Behavioral Risk Factor Surveillance System (BRFSS) survey. MATERIALS AND METHODS A cross-sectional analysis of men aged between 55 and 69 who responded to the PSA screening and alcohol consumption portions of the 2018 BRFSS survey was performed. Alcohol consumption was assessed according with the Centers for Disease Control and Prevention definition of binge and heavy drinking. Rates of PSA screening between binge and non-binge drinkers and among heavy and non-heavy drinkers were compared. A complex weighted multivariable logistic regression model, adjusted for socio-economic covariates and weighted using BRFSS sample weights, was used to test the association between the self-reported alcohol use and the odds of PSA screening. RESULTS Among 57,774 men eligible for PCa screening, there were 8,276 binge drinkers with an unadjusted PSA screening prevalence of 37% versus 40% in the non-binge drinking group (P = .018). Among 3,836 heavy drinkers, the unadjusted PSA screening prevalence was 34% versus 40% in non-heavy drinkers (P < .001). In the multivariable analysis, only heavy drinking status was significantly associated with a lower odds of PSA screening (OR: 0.84, 95% CI: 0.72-0.98, P = .02). CONCLUSION Given that alcohol overuse may increase the risk of developing cancer, our finding of lower utilization of PCa screening among heavy drinkers is noteworthy. Efforts to support guideline-concordant cancer screening among heavy drinkers may represent an important strategy to reduce the burden of cancer in these men.
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Affiliation(s)
- Nicola Frego
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Urology, Humanitas Research Hospital- IRCCS, Milan, Italy
| | - Khalid Alkhatib
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Muhieddine Labban
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Mara Koelker
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Nora Y Osman
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sonja R Solomon
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Quoc-Dien Trinh
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Alexander P Cole
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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7
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Zaveri S, Nevid D, Ru M, Moshier E, Pisapati K, Reyes SA, Port E, Romanoff A. Racial Disparities in Time to Treatment Persist in the Setting of a Comprehensive Breast Center. Ann Surg Oncol 2022; 29:6692-6703. [PMID: 35697955 DOI: 10.1245/s10434-022-11971-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 05/16/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND Racial disparities in breast cancer care have been linked to treatment delays. We explored whether receiving care at a comprehensive breast center could mitigate disparities in time to treatment. METHODS Retrospective chart review identified breast cancer patients who underwent surgery from 2012 to 2018 at a comprehensive breast center. Time-to-treatment intervals were compared among self-identified racial and ethnic groups by negative binomial regression models. RESULTS Overall, 2094 women met the inclusion criteria: 1242 (59%) White, 262 (13%) Black, 302 (14%) Hispanic, 105 (5%) Asian, and 183 (9%) other race or ethnicity. Black and Hispanic patients more often had Medicaid insurance, higher American Society of Anesthesiologists (ASA) scores, advanced-stage breast cancer, mastectomy, and additional imaging after breast center presentation (p < 0.05). After controlling for other variables, racial or ethnic minority groups had consistently longer intervals to treatment, with Black women experiencing the greatest disparity (incidence rate ratio 1.42). Time from initial comprehensive breast center visit to treatment was also significantly shorter in White patients versus non-White patients (p < 0.0001). Black race, Medicaid insurance/being uninsured, older age, earlier stage, higher ASA score, undergoing mastectomy, having reconstruction, and requiring additional pretreatment work-up were associated with a longer time from initial visit at the comprehensive breast center to treatment on multivariable analysis (p < 0.05). CONCLUSION Racial or ethnic minority groups have significant delays in treatment even when receiving care at a comprehensive breast center. Influential factors include insurance delays and necessity of additional pretreatment work-up. Specific policies are needed to address system barriers in treatment access.
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Affiliation(s)
- Shruti Zaveri
- Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniella Nevid
- Dubin Breast Center, Tisch Cancer Institute, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Meng Ru
- Department of Population Health Science and Policy, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Erin Moshier
- Department of Population Health Science and Policy, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kereeti Pisapati
- Dubin Breast Center, Tisch Cancer Institute, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sylvia A Reyes
- Dubin Breast Center, Tisch Cancer Institute, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Elisa Port
- Dubin Breast Center, Tisch Cancer Institute, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anya Romanoff
- Department of Global Health and Health System Design, The Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,The New York Academy of Medicine, 1216 Fifth Avenue, Room 556C, New York, NY, 10029, USA.
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8
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Hu X, Fujiwara T, Houdek MT, Chen L, Huang W, Sun Z, Sun Y, Yan W. Impact of racial disparities and insurance status in patients with bone sarcomas in the USA : a population-based cohort study. Bone Joint Res 2022; 11:278-291. [PMID: 35549518 PMCID: PMC9130676 DOI: 10.1302/2046-3758.115.bjr-2021-0258.r2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Aims Socioeconomic and racial disparities have been recognized as impacting the care of patients with cancer, however there are a lack of data examining the impact of these disparities on patients with bone sarcoma. The purpose of this study was to examine socioeconomic and racial disparities that impact the oncological outcomes of patients with bone sarcoma. Methods We reviewed 4,739 patients diagnosed with primary bone sarcomas from the Surveillance, Epidemiology and End Results (SEER) registry between 2007 and 2015. We examined the impact of race and insurance status associated with the presence of metastatic disease at diagnosis, treatment outcome, and overall survival (OS). Results Patients with Medicaid (odds ratio (OR) 1.41; 95% confidence interval (CI) 1.15 to 1.72) and uninsured patients (OR 1.90; 95% CI 1.26 to 2.86) had higher risks of metastatic disease at diagnosis compared to patients with health insurance. Compared to White patients, Black (OR 0.63, 95% CI 0.47 to 0.85) and Asian/Pacific Islander (OR 0.65, 95% CI 0.46 to 0.91) were less likely to undergo surgery. In addition, Black patients were less likely to receive chemotherapy (OR 0.67, 95% CI 0.49 to 0.91) compared to White patients. In patients with chondrosarcoma, those with Medicaid had worse OS compared to patients with insurance (hazard ratio (HR) 1.65, 95% CI 1.06 to 2.56). Conclusion In patients with a bone sarcoma, the cancer stage at diagnosis varied based on insurance status, and racial disparities were identified in treatment. Further studies are needed to identify modifiable factors which can mitigate socioeconomic and racial disparities found in patients with bone sarcomas. Cite this article: Bone Joint Res 2022;11(5):278–291.
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Affiliation(s)
- Xianglin Hu
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Tomohiro Fujiwara
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Matthew T Houdek
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Lingxiao Chen
- Faculty of Medicine and Health, University of Sydney, The Kolling Institute, Sydney, Australia
| | - Wending Huang
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhengwang Sun
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yangbai Sun
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wangjun Yan
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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9
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Fu SJ, Arnow K, Trickey A, Spain DA, Morris A, Knowlton L. Financial Burden of Traumatic Injury Amongst the Privately Insured. Ann Surg 2022; 275:424-432. [PMID: 34596072 DOI: 10.1097/sla.0000000000005225] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We sought to evaluate the overall financial burden associated with traumatic injury amongst patients with private insurance and assess the effect of high deductible plans on out-of-pocket costs (OOPCs). SUMMARY OF BACKGROUND DATA Traumatic injury can be a source of unexpected financial burden for households. However, the effect of increasing participation in higher cost-sharing private health insurance plans remains unknown. METHODS We conducted a retrospective cohort observational study, using the Clinformatics Data Mart Database, a nationwide single-payer administrative claims database to identify US adults who required emergency department services or hospital admission for single traumatic injury from 2008 to 2018. A 2-part model using a logistic regression and a generalized linear model with gamma distribution and log link was used to evaluate 12-month OOPCs after traumatic injury. Multivariable logistic regression was used to evaluate the likelihood of catastrophic health expenditure (CHE) after injury. RESULTS Of 426,945 included patients, 53% were male, 71% were white, and median age was 42 years. Patients faced monthly OOPC of $660 at the time of their injury. High deductible plan enrollment was associated with an increase of $1703 in 12-month OOPC after trauma, compared to those covered by traditional health plans. In addition to high deductible health plan enrollment, worsening injury severity and longer hospital stays were also associated with increased 12-month OOPC after trauma. Non-white minorities paid less 12-month OOPC after trauma compared to non-Hispanic white patients, but also used fewer services. Overall, the incidence of CHE was 5%; however high-deductible health plan enrollees faced a 13% chance of CHE. CONCLUSIONS Privately insured trauma patients face substantial OOPCs at the time of their injuries. High-deductible health plans are associated with increased financial vulnerability after trauma.
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Affiliation(s)
- Sue J Fu
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
- Health Research and Development, Veteran Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Katherine Arnow
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
| | - Amber Trickey
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
| | - David A Spain
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
| | - Arden Morris
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
| | - Lisa Knowlton
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
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10
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Jiang JY, Reid EG. Impact of Insurance Status on Outcomes in Individuals with AIDS-Defining Cancers. AIDS Res Hum Retroviruses 2021; 37:884-892. [PMID: 34583514 PMCID: PMC8817691 DOI: 10.1089/aid.2021.0102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This single-center, retrospective cohort study evaluates whether insurance coverage and Ryan White HIV/AIDS Program assistance are associated with differences in treatment and survival outcomes in Kaposi sarcoma and aggressive non-Hodgkin lymphoma among people with HIV (PWH). Participants were classified as having private, Medicare, Medicaid, or no insurance. Hazard ratios (HRs) for progression and death were estimated using Cox proportional hazards regression models. Propensity score weighting was used to adjust for imbalances in age, ethnicity, and performance status. Among 191 participants, 18% had private insurance, 14% had Medicare, 46% had Medicaid, and 23% were uninsured. Forty-four percent received Ryan White assistance. Participants with Medicare and those without Ryan White assistance were older. Those without Ryan White assistance also had worse performance status. No differences in CD4+ T cell counts, HIV viral loads, highly active antiretroviral therapy adherence, time to treatment, and regimen selection were detected. After adjustment with propensity score weighting, participants without Ryan White assistance had a greater risk of death [adjusted HR 4.06, 95% confidence interval (CI) 1.45-11.41, p = .008] and progression (adjusted HR 3.39, 95% CI 1.43-8.05, p = .006) than those with Ryan White assistance. We conclude that among people with AIDS-defining cancers, those with Medicare and those without Ryan White assistance had higher mortality, possibly due to age and other medical comorbidities. Notably, underinsured PWH who received Ryan White assistance experienced similar outcomes as those with private insurance.
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Affiliation(s)
- Jun Yang Jiang
- Department of Medicine, UC San Diego Health System, San Diego, California, USA
| | - Erin Gourley Reid
- Department of Medicine, UC San Diego Health System, San Diego, California, USA
- Moores Cancer Center, UC San Diego Health System, San Diego, California, USA
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11
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Papageorge MV, Evans DB, Tseng JF. Health Care Disparities and the Future of Pancreatic Cancer Care. Surg Oncol Clin N Am 2021; 30:759-771. [PMID: 34511195 DOI: 10.1016/j.soc.2021.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
There have been tremendous advances in the diagnosis and treatment of pancreatic cancer in the past decade, yet we are failing to achieve equitable outcomes for all patient populations. Disparities exist in the incidence, diagnosis, treatment, and outcomes of patients with pancreatic cancer. Inequities are based on racial and ethnic group, sex, socioeconomic status, and geography. To address disparities, future steps must focus on research methods, including collection and methodology, and policy measures, including access, patient tools, hospital incentives, and workforce diversity. Through these comprehensive efforts, we can begin to rectify inequitable care for treatment of patients with pancreatic cancer.
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Affiliation(s)
- Marianna V Papageorge
- Boston Medical Center, Boston University School of Medicine, 88 East Newton Street, Collamore - C500, Boston, MA 02118, USA. https://twitter.com/MPapageorge_MD
| | - Douglas B Evans
- Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Wilwaukee, WI 53226, USA. https://twitter.com/@DougEvans2273
| | - Jennifer F Tseng
- Boston Medical Center, Boston University School of Medicine, 88 East Newton Street, Collamore - C500, Boston, MA 02118, USA.
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12
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Jaramillo JD, Arnow K, Trickey AW, Dickerson K, Wagner TH, Harris AHS, Tran LD, Bereknyei S, Morris AM, Spain DA, Knowlton LM. Acquisition of Medicaid at the time of injury: An opportunity for sustainable insurance coverage. J Trauma Acute Care Surg 2021; 91:249-259. [PMID: 33783416 DOI: 10.1097/ta.0000000000003195] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Uninsured trauma patients are at higher risk of mortality, limited access to postdischarge resources, and catastrophic health expenditure. Hospital Presumptive Eligibility (HPE), enacted with the 2014 Affordable Care Act, enables uninsured patients to be screened and acquired emergency Medicaid at the time of hospitalization. We sought to identify factors associated with successful acquisition of HPE insurance at the time of injury, hypothesizing that patients with higher Injury Severity Score (ISS) (ISS >15) would be more likely to be approved for HPE. METHODS We identified Medicaid and uninsured patients aged 18 to 64 years with a primary trauma diagnosis (International Classification of Diseases, Tenth Revision) in a large level I trauma center between 2015 and 2019. We combined trauma registry data with review of electronic medical records, to determine our primary outcome, HPE acquisition. Descriptive and multivariate analyses were performed. RESULTS Among 2,320 trauma patients, 1,374 (59%) were already enrolled in Medicaid at the time of hospitalization. Among those uninsured at arrival, 386 (40.8%) acquired HPE before discharge, and 560 (59.2%) remained uninsured. Hospital Presumptive Eligibility patients had higher ISS (ISS >15, 14.8% vs. 5.7%; p < 0.001), longer median length of stay (2 days [interquartile range, 0-5 days] vs. 0 [0-1] days, p < 0.001), were more frequently admitted as inpatients (64.5% vs. 33.6%, p < 0.001), and discharged to postacute services (11.9% vs. 0.9%, p < 0.001). Patient, hospital, and policy factors contributed to HPE nonapproval. In adjusted analyses, Hispanic ethnicity (vs. non-Hispanic Whites: aOR, 1.58; p = 0.02) and increasing ISS (p ≤ 0.001) were associated with increased likelihood of HPE approval. CONCLUSION The time of hospitalization due to injury is an underused opportunity for intervention, whereby uninsured patients can acquire sustainable insurance coverage. Opportunities to increase HPE acquisition merit further study nationally across trauma centers. As administrative and trauma registries do not capture information to compare HPE and traditional Medicaid patients, prospective insurance data collection would help to identify targets for intervention. LEVEL OF EVIDENCE Economic, level IV.
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Affiliation(s)
- Joshua D Jaramillo
- From the Division of General Surgery, Department of Surgery (J.D.J., K.D.), Stanford University School of Medicine; Department of Surgery, (K.A., A.W.T., T.H.W., A.H.S.H., L.D.T., S.B., A.M.M., L.M.K.), Stanford-Surgery Policy Improvement Research and Education Center, Stanford University School of Medicine; and Department of Surgery (D.A.S., L.M.K.), Section of Trauma, Surgical Critical Care and Acute Care Surgery (L.M.K.), Stanford University, Stanford, California
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13
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Lawson MB, Lee CI, Hippe DS, Chennupati S, Fedorenko CR, Malone KE, Ramsey SD, Lee JM. Receipt of Screening Mammography by Insured Women Diagnosed With Breast Cancer and Impact on Outcomes. J Natl Compr Canc Netw 2021; 19:1156-1164. [PMID: 34330103 DOI: 10.6004/jnccn.2020.7801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 12/21/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND The purpose of this study was to determine factors associated with receipt of screening mammography by insured women before breast cancer diagnosis, and subsequent outcomes. PATIENTS AND METHODS Using claims data from commercial and federal payers linked to a regional SEER registry, we identified women diagnosed with breast cancer from 2007 to 2017 and determined receipt of screening mammography within 1 year before diagnosis. We obtained patient and tumor characteristics from the SEER registry and assigned each woman a socioeconomic deprivation score based on residential address. Multivariable logistic regression models were used to evaluate associations of patient and tumor characteristics with late-stage disease and nonreceipt of mammography. We used multivariable Cox proportional hazards models to identify predictors of subsequent mortality. RESULTS Among 7,047 women, 69% (n=4,853) received screening mammography before breast cancer diagnosis. Compared with women who received mammography, those with no mammography had a higher proportion of late-stage disease (34% vs 10%) and higher 5-year mortality (18% vs 6%). In multivariable modeling, late-stage disease was most associated with nonreceipt of mammography (odds ratio [OR], 4.35; 95% CI, 3.80-4.98). The Cox model indicated that nonreceipt of mammography predicted increased risk of mortality (hazard ratio [HR], 2.00; 95% CI, 1.64-2.43), independent of late-stage disease at diagnosis (HR, 5.00; 95% CI, 4.10-6.10), Charlson comorbidity index score ≥1 (HR, 2.75; 95% CI, 2.26-3.34), and negative estrogen receptor/progesterone receptor status (HR, 2.09; 95% CI, 1.67-2.61). Nonreceipt of mammography was associated with younger age (40-49 vs 50-59 years; OR, 1.69; 95% CI, 1.45-1.96) and increased socioeconomic deprivation (OR, 1.05 per decile increase; 95% CI, 1.03-1.07). CONCLUSIONS In a cohort of insured women diagnosed with breast cancer, nonreceipt of screening mammography was significantly associated with late-stage disease and mortality, suggesting that interventions to further increase uptake of screening mammography may improve breast cancer outcomes.
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Affiliation(s)
- Marissa B Lawson
- 1Department of Radiology, University of Washington School of Medicine; and
| | - Christoph I Lee
- 1Department of Radiology, University of Washington School of Medicine; and.,2Hutchinson Institute for Cancer Outcomes Research, and
| | - Daniel S Hippe
- 1Department of Radiology, University of Washington School of Medicine; and
| | | | | | - Kathleen E Malone
- 3Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Scott D Ramsey
- 2Hutchinson Institute for Cancer Outcomes Research, and.,3Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Janie M Lee
- 1Department of Radiology, University of Washington School of Medicine; and.,2Hutchinson Institute for Cancer Outcomes Research, and
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Cho DY, Park J, Kim DS. The impact of expanding health insurance coverage for anti-cancer drugs on cancer survival in Korea. Cancer Med 2021; 10:4555-4563. [PMID: 34145980 PMCID: PMC8267115 DOI: 10.1002/cam4.3979] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 03/31/2021] [Accepted: 05/03/2021] [Indexed: 01/10/2023] Open
Abstract
Background To reduce out‐of‐pocket costs, the Korean government expanded health insurance reimbursement in anti‐cancer drugs for cancer patients in 2013. Our objective was to examine the impact of the benefit coverage expansion policy on healthcare utilization and overall survival (OS) among patients with six types of solid cancer after the policy of expanding health insurance coverage. Methods This study analyzed a before‐and‐after retrospective cohort of patients newly diagnosed with six types of solid cancer (stomach cancer, colorectal cancer, lung cancer, liver cancer, breast cancer, and prostate cancer) from January 1, 2009 to December 31, 2015 in Korea. The intervention was the expansion of reimbursement in 2013. Multivariate Cox proportional hazards regression was used to estimate the policy effect. Results In total, 142,579 before and 147,760 patients after the benefit expansion, and after matched by age, gender, and stage, 132,440 before and 132,440 patients after policy were included in the analysis. Almost total medical expenditure increased for five types of cancer increased. The expansion of health insurance reimbursement was associated with significantly lower overall mortality compared with pre‐policy mortality for all six cancer sites. Conclusion The policy of expanding health insurance reimbursement might have been associated with a significant increase in survival among cancer patients by ensuring access to health care and medicine. Although the reimbursement expansion timing differs for each cancer, it is believed that eliminating delayed treatment might rather lead to reduce medical expenses and improve health outcomes.
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Affiliation(s)
- Do-Yeon Cho
- Department of Research, Health Insurance Review & Assessment Service, Wonju, South Korea
| | - Juhee Park
- Department of Research, Health Insurance Review & Assessment Service, Wonju, South Korea
| | - Dong-Sook Kim
- Department of Research, Health Insurance Review & Assessment Service, Wonju, South Korea
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15
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Romanoff A, Olasehinde O, Goldman DA, Alatise OI, Constable J, Monu N, Knapp GC, Odujoko O, Onabanjo E, Adisa AO, Arowolo AO, Omisore AD, Famurewa OC, Anderson BO, Gemignani ML, Kingham TP. Opportunities for Improvement in the Administration of Neoadjuvant Chemotherapy for T4 Breast Cancer: A Comparison of the U.S. and Nigeria. Oncologist 2021; 26:e1589-e1598. [PMID: 33955123 DOI: 10.1002/onco.13814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 04/08/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) is an integral component of T4 breast cancer (BCa) treatment. We compared response to NAC for T4 BCa in the U.S. and Nigeria to direct future interventions. MATERIALS AND METHODS Cross-sectional retrospective analysis included all patients with non-metastatic T4 BCa treated from 2010 to 2016 at Memorial Sloan Kettering Cancer Center (New York, New York) and Obafemi Awolowo University Teaching Hospitals Complex (Ile Ife, Nigeria). Pathologic complete response (pCR) and survival were compared and factors contributing to disparities evaluated. RESULTS Three hundred and eight patients met inclusion criteria: 157 (51%) in the U.S. and 151 (49%) in Nigeria. All U.S. patients received NAC and surgery compared with 93 (62%) Nigerian patients. Fifty-six out of ninety-three (60%) Nigerian patients completed their prescribed course of NAC. In Nigeria, older age and higher socioeconomic status were associated with treatment receipt. Fewer patients in Nigeria had immunohistochemistry performed (100% U.S. vs. 18% Nigeria). Of those with available receptor subtype, 18% (28/157) of U.S. patients were triple negative versus 39% (9/23) of Nigerian patients. Overall pCR was seen in 27% (42/155) of U.S. patients and 5% (4/76) of Nigerian patients. Five-year survival was significantly shorter in Nigeria versus the U.S. (61% vs. 72%). However, among the subset of patients who received multimodality therapy, including NAC and surgery with curative intent, 5-year survival (67% vs. 72%) and 5-year recurrence-free survival (48% vs. 61%) did not significantly differ between countries. CONCLUSION Addressing health system, socioeconomic, and psychosocial barriers is necessary for administration of complete NAC to improve BCa outcomes in Nigeria. IMPLICATIONS FOR PRACTICE This cross-sectional retrospective analysis of patients with T4 breast cancer in Nigeria and the U.S. found a significant difference in pathologic complete response to neoadjuvant chemotherapy (5% Nigeria vs. 27% U.S.). Five-year survival was shorter in Nigeria, but in patients receiving multimodality treatment, including neoadjuvant chemotherapy and surgery with curative intent, 5-year overall and recurrence-free survival did not differ between countries. Capacity-building efforts in Nigeria should focus on access to pathology services to direct systemic therapy and promoting receipt of complete chemotherapy to improve outcomes.
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Affiliation(s)
- Anya Romanoff
- Department of Global Health and Health System Design, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Surgery, Global Cancer Disparities Initiatives, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Olalekan Olasehinde
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile Ife, Nigeria
| | - Debra A Goldman
- Department of Epidemiology and Biostatics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Olusegun I Alatise
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile Ife, Nigeria
| | - Jeremy Constable
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ngozi Monu
- Weill Cornell School of Medicine, New York, New York, USA
| | - Gregory C Knapp
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Oluwole Odujoko
- Department of Pathology, Obafemi Awolowo University Teaching Hospitals Complex, Ile Ife, Nigeria
| | - Emmanuella Onabanjo
- African Research Group for Oncology, Obafemi Awolowo University Teaching Hospitals Complex, Ile Ife, Nigeria
| | - Adewale O Adisa
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile Ife, Nigeria
| | - Adeolu O Arowolo
- Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile Ife, Nigeria
| | - Adeleye D Omisore
- Department of Radiology, Obafemi Awolowo University Teaching Hospitals Complex, Ile Ife, Nigeria
| | - Olusola C Famurewa
- Department of Radiology, Obafemi Awolowo University Teaching Hospitals Complex, Ile Ife, Nigeria
| | - Benjamin O Anderson
- Departments of Surgery and Global Health, University of Washington, Seattle, Washington, USA.,Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Mary L Gemignani
- Department of Surgery, Breast Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - T Peter Kingham
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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16
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Cole AP, Herzog P, Iyer HS, Marchese M, Mahal BA, Lipsitz SR, Nyambose J, Gershman ST, Kennedy M, Merriam G, Rebbeck TR, Trinh QD. Racial differences in the treatment and outcomes for prostate cancer in Massachusetts. Cancer 2021; 127:2714-2723. [PMID: 33999405 DOI: 10.1002/cncr.33564] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 03/03/2021] [Accepted: 03/05/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Massachusetts is a northeastern state with universally mandated health insurance since 2006. Although Black men have generally worse prostate cancer outcomes, emerging data suggest that they may experience equivalent outcomes within a fully insured system. In this setting, the authors analyzed treatments and outcomes of non-Hispanic White and Black men in Massachusetts. METHODS White and Black men who were 20 years old or older and had been diagnosed with localized intermediate- or high-risk nonmetastatic prostate cancer in 2004-2015 were identified in the Massachusetts Cancer Registry. Adjusted logistic regression models were used to assess predictors of definitive therapy. Adjusted and unadjusted survival models compared cancer-specific mortality. Interaction terms were then used to assess whether the effect of race varied between counties. RESULTS A total of 20,856 men were identified. Of these, 19,287 (92.5%) were White. There were significant county-level differences in the odds of receiving definitive therapy and survival. Survival was worse for those with high-risk cancer (adjusted hazard ratio [HR], 1.50; 95% CI, 1.4-1.60) and those with public insurance (adjusted HR for Medicaid, 1.69; 95% CI, 1.38-2.07; adjusted HR for Medicare, 1.2; 95% CI, 1.14-1.35). Black men were less likely to receive definitive therapy (adjusted odds ratio, 0.78; 95% CI, 0.74-0.83) but had a 17% lower cancer-specific mortality (adjusted HR, 0.83; 95% CI, 0.7-0.99). CONCLUSIONS Despite lower odds of definitive treatment, Black men experience decreased cancer-specific mortality in comparison with White men in Massachusetts. These data support the growing body of research showing that Black men may achieve outcomes equivalent to or even better than those of White men within the context of a well-insured population. LAY SUMMARY There is a growing body of evidence showing that the excess risk of death among Black men with prostate cancer may be caused by disparities in access to care, with few or no disparities seen in universally insured health systems such as the Veterans Affairs and US Military Health System. Therefore, the authors sought to assess racial disparities in prostate cancer in Massachusetts, which was the earliest US state to mandate universal insurance coverage (in 2006). Despite lower odds of definitive treatment, Black men with prostate cancer experience reduced cancer-specific mortality in comparison with White men in Massachusetts. These data support the growing body of research showing that Black men may achieve outcomes equivalent to or even better than those of White men within the context of a well-insured population.
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Affiliation(s)
- Alexander P Cole
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Peter Herzog
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hari S Iyer
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Maya Marchese
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Brandon A Mahal
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joshua Nyambose
- Massachusetts Department of Public Health, Boston, Massachusetts
| | - Susan T Gershman
- Massachusetts Department of Public Health, Boston, Massachusetts
| | - Mark Kennedy
- Boston Public Health Commission, Boston, Massachusetts
| | - Gail Merriam
- Massachusetts Department of Public Health, Boston, Massachusetts
| | - Timothy R Rebbeck
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Quoc-Dien Trinh
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Cole AP, Lipsitz SR, Kibel AS, Mahal BA, Melnitchouk N, Cooper Z, Trinh QD. Is Medicaid expansion associated with increases in palliative treatments for metastatic cancer? J Comp Eff Res 2021; 10:733-741. [PMID: 33880936 DOI: 10.2217/cer-2020-0178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background: Medicaid expansion following the 2010 Affordable Care Act has an unknown impact on palliative treatments. Materials & methods: This registry-based study of individuals with metastatic cancer from 2010 to 2016 identified men and women with metastatic cancer in expansion and non-expansion states who received palliative treatments. A mixed effects logistic regression compared trends in expansion and non-expansion states and generated risk-adjusted probabilities or receiving palliative treatments each year. Results: Despite lower baseline use of palliative treatments, the rate of change was more rapid in expansion states (odds ratio [OR]: 1.02; 95% CI: 1.01-1.03; p < 0.001). The adjusted probability of receiving palliative treatments rose from 21.3 to 26.0% in non-expansion states, and from 19.7 to 26.9% in expansion states. Conclusion: Use of palliative treatments among metastatic cancer patients increased from 2010 to 2016 with a significantly greater increase in Medicaid expansion states, even when adjusting for demographic differences between states.
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Affiliation(s)
- Alexander P Cole
- Division of Urological Surgery & Center for Surgery & Public Health, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Stuart R Lipsitz
- Division of General Internal Medicine & Center for Surgery & Public Health, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Adam S Kibel
- Division of Urological Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Brandon A Mahal
- Department of Radiation Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
| | - Nelya Melnitchouk
- Department of Surgery & Center for Surgery & Public Health, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Zara Cooper
- Department of Surgery & Center for Surgery & Public Health, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Quoc-Dien Trinh
- Division of Urological Surgery & Center for Surgery & Public Health, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Urology Residency Training in Medically Underserved Areas Through the Integration of a Federally Qualified Health Center Rotation. Urology 2021; 149:52-57. [PMID: 33421443 DOI: 10.1016/j.urology.2020.11.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/11/2020] [Accepted: 11/08/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To identify workforce related barriers to urologic care in Medically Underserved Areas (MUA) and Health Professional Shortage Areas (HPSA). Federally Qualified Health Centers (FQHC) are community-based organizations that aim to close gaps, but little is known about exposure to underserved areas during residency training. METHODS The objective of this study was to characterize the experiences of urology residents who participated in a rotation within a FQHC. The study consisted of: (1) 12-item post-rotation self-assessment (2) review of career paths of former graduates who completed the rotation, and (3) retrospective review of patients treated at FQHC from 2016 to 2018. RESULTS There were a total of 1735 patient visits, 97 were for cystoscopy, 76.36% of patients had Medicaid or no insurance. There were 1092 unique patients seen and 281 (25.73%) were referred for surgery. A majority of residents (100%) stated they had a better appreciation of treating patients in underserved areas. A majority of residents (71.6%) of residents said they were more likely to practice in an underserved area after residency. Among former graduates who rotated through the clinic, 100% (n = 4) were practicing in a MUA or HPSA. CONCLUSION The integration of an FQHC during urology residency training was associated with highly favorable satisfaction by trainees. Given persistent workforce related shortages in urology, these findings support exposure to medically underserved areas during training.
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Elkbuli A, Byrne MM, Zhao W, Sutherland M, McKenney M, Godinez Y, Dave DJ, Bouzoubaa L, Koru-Sengul T. Gender disparities in lung cancer survival from an enriched Florida population-based cancer registry. Ann Med Surg (Lond) 2020; 60:680-685. [PMID: 33318793 PMCID: PMC7723764 DOI: 10.1016/j.amsu.2020.11.081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 11/26/2020] [Accepted: 11/28/2020] [Indexed: 12/24/2022] Open
Abstract
Background Previous studies have revealed gender disparities in lung cancer survivorship, but comprehensive inclusion of clinical/individual variables which affect outcomes is underreported. We utilized the Florida Data Cancer System (FCDS) to examine associations between gender and lung cancer survivorship while controlling for prognostic variables on a large population-based scale. Methods A retrospective cohort analysis utilizing the FCDS, linked to Florida Agency for Health Care Administration and US Census Bureau tracts for patients diagnosed with primary lung cancer (n = 165,465) from 1996 to 2007. Primary outcome measures included median survival time and mortality. Multivariable Cox regression models, independent sample T-tests, and descriptive statistics were utilized with significance defined as p < 0.05. Results 165,465 cases were analyzed revealing 44.3% females and 55.7% males. The majority of patients were white/Caucasian, males, middle-high socioeconomic status, lived in urban areas, and geriatric age. Females had longer median survival compared to males (9.6 vs 7.1 months). Multivariable analyses showed that women had better survival after controlling for sociodemographic, clinical, and comorbidity covariates. Males had higher risk of mortality than females (aHR = 1.17, 95%CI 1.14-1.19, p < 0.01). Conclusions Individuals of higher socioeconomic status experienced greater survivorship compared to those of lower socioeconomic status. Women experienced significantly better survival for lung cancer at multiple time frames after controlling for covariates compared to men. Interventions aimed at public education and access to high-quality healthcare are needed to ameliorate socioeconomic and gender-based disparities in lung cancer survivorship. Future studies should investigate gender differences in lung cancer while incorporating individual socioeconomic status and treatment received.
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Affiliation(s)
- Adel Elkbuli
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120, NW 14Street, Don Soffer Clinical Research Center, Miami, FL, 33136, USA.,Department of Surgery, Kendall Regional Medical Center, 11750 SW 40th St, Miami, FL, 33175, USA
| | - Margaret M Byrne
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120, NW 14Street, Don Soffer Clinical Research Center, Miami, FL, 33136, USA.,Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL, 33136, USA
| | - Wei Zhao
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL, 33136, USA
| | - Mason Sutherland
- Department of Surgery, Kendall Regional Medical Center, 11750 SW 40th St, Miami, FL, 33175, USA
| | - Mark McKenney
- Department of Surgery, Kendall Regional Medical Center, 11750 SW 40th St, Miami, FL, 33175, USA.,Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Yeissen Godinez
- Department of Internal Medicine, Kendall Regional Medical Center, 11750 SW 40th St, Miami, FL, 33175, USA
| | - Devina J Dave
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120, NW 14Street, Don Soffer Clinical Research Center, Miami, FL, 33136, USA
| | - Layla Bouzoubaa
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120, NW 14Street, Don Soffer Clinical Research Center, Miami, FL, 33136, USA.,Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL, 33136, USA
| | - Tulay Koru-Sengul
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120, NW 14Street, Don Soffer Clinical Research Center, Miami, FL, 33136, USA.,Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL, 33136, USA
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20
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Alimena S, Sullivan MW, Philp L, Dorney K, Hubbell H, Del Carmen MG, Goodman A, Bregar A, Growdon WB, Eisenhauer EL, Sisodia RC. Patient reported outcome measures among patients with vulvar cancer at various stages of treatment, recurrence, and survivorship. Gynecol Oncol 2020; 160:252-259. [PMID: 33139040 DOI: 10.1016/j.ygyno.2020.10.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/16/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Our goal was to pragmatically describe patient reported outcomes (PROs) in a typical clinic population of vulvar cancer patients, as prior studies of vulvar cancer PROs have examined clinical trial participants. METHODS A prospective PRO program was implemented in the Gynecologic Oncology clinic of a tertiary academic institution in January 2018. Vulvar cancer patients through September 2019 were administered the European Organization for the Research and Treatment of Cancer Quality of life Questionnaire, the Patient Reported Outcome Measurement Information System Instrumental and Emotional Support Scales, and the Functional Assessment of Cancer Therapy-Vulvar questionnaire. Binary logistic regressions were performed to determine adjusted odds ratios for adverse responses to individual questions by insurance, stage, age, time since diagnosis, recurrence, radiation, and surgical radicality. RESULTS Seventy vulvar cancer patients responded to PROs (85.4% response rate). Seventy-one percent were > 1 year since diagnosis, 61.4% had stage I disease, and 28.6% recurred. Publicly insured women had less support and worse quality of life (QOL, aOR 4.15, 95% CI 1.00-17.32, p = 0.05). Women who recurred noted more interference with social activities (aOR 4.45, 95% CI 1.28-15.41, p = 0.019) and poorer QOL (aOR 5.22 95% CI 1.51-18.10, p = 0.009). There were no major differences by surgical radicality. Those >1 year since diagnosis experienced less worry (aOR 0.17, 95% CI 0.04-0.63, p = 0.008). CONCLUSIONS Surgical radicality does not affect symptoms or QOL in vulvar cancer patients, whereas insurance, recurrence, and time since diagnosis do. This data can improve counseling and awareness of patient characteristics that would benefit from social services referral.
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Affiliation(s)
- Stephanie Alimena
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Mackenzie W Sullivan
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lauren Philp
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Katelyn Dorney
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Harrison Hubbell
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Annekathryn Goodman
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Amy Bregar
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Whitfield B Growdon
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric L Eisenhauer
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rachel Clark Sisodia
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Wang Z, Yang L, Liu S, Li H, Zhang X, Wang N, Ji J. Effects of insurance status on long-term survival among non-small cell lung cancer (NSCLC) patients in Beijing, China: A population-based study. Chin J Cancer Res 2020; 32:596-604. [PMID: 33223754 PMCID: PMC7666783 DOI: 10.21147/j.issn.1000-9604.2020.05.04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Objective To evaluate the effects of health insurance status on long-term cancer-specific survival of non-small cell lung cancer (NSCLC) in Beijing, China, using a population-based cancer registry data. Methods Information on NSCLC patients diagnosed in 2008 was derived from the Beijing Cancer Registry. The medical records of 1,134 cases were sampled and re-surveyed to obtain information on potential risk factors. Poorly-insured status was defined as Uninsured and New Rural Cooperative Medical Insurance Scheme (NRCMS), while well-insured included Urban Employees Basic Medical Insurance (UEBMI) and Free Medical Care (FMC). To estimate survival outcomes, individuals were followed-up until December 31, 2018. Cancer-specific survival probabilities at 5 and 10 years after diagnosis were estimated using the Kaplan-Meier method. Log-rank test was used to compare long-term survival with different characteristics. Multivariable Cox proportional hazard regression model was used to examine the relative effect of insurance status on cancer-specific mortality. Results Well-insured NSCLC patients have longer cancer-specific survival than poorly-insured individuals [hazard ratio (HR)=0.81; 95% confidence interval (95% CI): 0.67−0.97), even after adjusting for age, gender, cancer stage, smoking status, family history and residential area. Older age and rural residence were associated with a higher risk of cancer-specific mortality (HR=1.03; 95% CI: 1.02−1.03 and HR=1.25; 95% CI: 1.07−1.46, respectively). Smoking individuals had a 41% higher long-term cancer-specific mortality risk than non-smoking ones (HR=1.41; 95% CI: 1.20−1.66). Conclusions NSCLC patients with good insurance status had better survival rates than those with poor insurance. An association was significant even after 10 years. Large population-based studies are needed to validate that high reimbursement insurance status can lead to the improvement of long-term cancer prognosis in China.
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Affiliation(s)
- Zheng Wang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Lei Yang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Beijing Office for Cancer Prevention and Control, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Shuo Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Beijing Office for Cancer Prevention and Control, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Huichao Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Beijing Office for Cancer Prevention and Control, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Xi Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Beijing Office for Cancer Prevention and Control, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Ning Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Beijing Office for Cancer Prevention and Control, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Jiafu Ji
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Center of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute, Beijing 100142, China
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