title: Health insurance status affects staging and influences treatment strategies in patients with hepatocellular carcinoma.
abstract: BACKGROUND
  Lack of health insurance is associated with poorer outcomes for patients with cancers amenable to early detection. The effect of insurance status on hepatocellular carcinoma (HCC) presentation stage and treatment outcomes has not been examined. We examined the effect of health insurance status on stage of presentation, treatment strategies, and survival in patients with HCC.
  
  
  METHODS
  The Tennessee Cancer Registry was queried for patients treated for HCC between January 2004 and December 2006. Patients were stratified by insurance status: (1) private insurance; (2) government insurance (non-Medicaid); (3) Medicaid; (4) uninsured. Logistic, Kaplan-Meier, and Cox models tested the effects of demographic and clinical covariates on the likelihood of having surgical or chemotherapeutic treatments and survival.
  
  
  RESULTS
  We identified 680 patients (208 private, 356 government, 75 Medicaid, 41 uninsured). Uninsured patients were more likely to be men, African American, and reside in an urban area (all P < 0.05). The uninsured were more likely to present with stage IV disease (P = 0.005). After adjusting for demographics and tumor stage, Medicaid and uninsured patients were less likely to receive surgical treatment (both P < 0.01) but were just as likely to be treated with chemotherapy (P ≥ 0.243). Survival was significantly better in privately insured patients and in those treated with surgery or chemotherapy (all P < 0.01). Demographic adjusted risk of death was doubled in the uninsured (P = 0.005).
  
  
  CONCLUSIONS
  Uninsured patients with HCC are more likely to present with late-stage disease. Although insurance status did not affect chemotherapy utilization, Medicaid and uninsured patients were less likely to receive surgical treatment.
authors.affiliation: Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA. vic.zaydfudim@vanderbilt.edu
authors.forename: Victor
authors.initials: V
authors.lastname: Zaydfudim
authors.forename: Martin A
authors.initials: MA
authors.lastname: Whiteside
authors.forename: Marie R
authors.initials: MR
authors.lastname: Griffin
authors.forename: Irene D
authors.initials: ID
authors.lastname: Feurer
authors.forename: J Kelly
authors.initials: JK
authors.lastname: Wright
authors.forename: C Wright
authors.initials: CW
authors.lastname: Pinson
mesh_terms: D000970:Antineoplastic Agents / Q000191:economics*; D006528:Carcinoma, Hepatocellular / Q000191:economics* / Q000473:pathology / Q000628:therapy; D017115:Catheter Ablation / Q000191:economics*; D003131:Combined Modality Therapy; D005260:Female; D006498:Hepatectomy / Q000191:economics*; D006801:Humans; D019458:Insurance Coverage; D007348:Insurance, Health; D008113:Liver Neoplasms / Q000191:economics* / Q000473:pathology / Q000628:therapy; D016031:Liver Transplantation / Q000191:economics*; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate; D016896:Treatment Outcome
chemical_list: D000970:Antineoplastic Agents