title: Health-insurance status is a determinant of the stage at presentation and of cancer control in European men treated with radical prostatectomy for clinically localized prostate cancer.
abstract: OBJECTIVE
  To determine whether health-insurance status might result in more localized stage at presentation, more favourable stage at surgery and in a lower rate of biochemical recurrence (BCR), in patients diagnosed with prostate cancer and treated with radical prostatectomy (RP), as despite uninhibited access to healthcare, private and public health insurance are available in most European countries.
  
  
  METHODS
  In all, 4442 consecutive men had RP in two large European centres, of whom 2372 had public and 2070 had private health insurance. The groups were compared for several variables according to insurance status (private vs public). Means and proportions tests were complemented with logistic regression or Kaplan-Meier analyses.
  
  
  RESULTS
  Serum prostate-specific antigen level (P < 0.001), clinical stage (P < 0.001), pathological Gleason sum (P = 0.02), positive surgical margin rate (18.4% vs 25.4%, P < 0.001), extracapsular extension rate (17.7% vs 20.0%, P = 0.047) and seminal vesicle invasion rate (9.6% vs 11.6%, P = 0.04) were more favourable in privately insured patients. Conversely, the rate of lymph-node involvement was higher in those with private than public insurance (4.4% vs 3.3%, P = 0.045). In univariate analyses addressing pathological variables, private insurance was invariably protective (all P < 0.05). The Kaplan-Meier analyses showed that privately insured patients had a lower rate of BCR after RP (log-rank P = 0.017).
  
  
  CONCLUSIONS
  Despite uninhibited access to healthcare, insurance status represents a rate-limiting variable, which affects stage at presentation and the outcome of cancer control.
authors.affiliation: Cancer Prognostics and Health Outcomes Unit, University of Montreal, Montreal, Quebec, Canada.
authors.forename: Andrea
authors.initials: A
authors.lastname: Gallina
authors.forename: Pierre I
authors.initials: PI
authors.lastname: Karakiewicz
authors.forename: Felix K-H
authors.initials: FK
authors.lastname: Chun
authors.forename: Alberto
authors.initials: A
authors.lastname: Briganti
authors.forename: Markus
authors.initials: M
authors.lastname: Graefen
authors.forename: Francesco
authors.initials: F
authors.lastname: Montorsi
authors.forename: Jochen
authors.initials: J
authors.lastname: Walz
authors.forename: Claudio
authors.initials: C
authors.lastname: Jeldres
authors.forename: Andreas
authors.initials: A
authors.lastname: Erbersdobler
authors.forename: Andrea
authors.initials: A
authors.lastname: Salonia
authors.forename: Nazareno
authors.initials: N
authors.lastname: Suardi
authors.forename: Federico
authors.initials: F
authors.lastname: Dehò
authors.forename: Thorsten
authors.initials: T
authors.lastname: Schlomm
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Scattoni
authors.forename: Alexander
authors.initials: A
authors.lastname: Haese
authors.forename: Hans
authors.initials: H
authors.lastname: Heinzer
authors.forename: Luc
authors.initials: L
authors.lastname: Valiquette
authors.forename: Patrizio
authors.initials: P
authors.lastname: Rigatti
authors.forename: Hartwig
authors.initials: H
authors.lastname: Huland
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005060:Europe; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D007348:Insurance, Health / Q000706:statistics & numerical data*; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D009367:Neoplasm Staging; D011379:Prognosis; D011468:Prostatectomy / Q000191:economics / Q000379:methods*; D011471:Prostatic Neoplasms / Q000191:economics / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome