title: Does increasing insurance improve outcomes for US cancer patients?
abstract: BACKGROUND
  Although debate continues on US healthcare and insurance reform, data are lacking on the effect of insurance on community-level cancer outcomes. Therefore, the objective of the present study was to examine the association of insurance and cancer outcomes.
  
  
  METHODS
  The US Census Bureau Current Population Survey, Small Area Health Insurance Estimates (2000) were used for the rates of uninsurance. Counties were divided into tertiles according to the uninsurance rates. The data were compared with the cancer incidence and survival for patients residing in counties captured by the Surveillance, Epidemiology, and End Results database (2000-2006). Aggregate patient data were collected of US adults (aged ≥18 y) diagnosed with the following cancers: pancreatic, esophageal, liver or bile duct, lung or bronchial, ovarian, colorectal, breast, prostate, melanoma, and thyroid. The outcomes included the stage at diagnosis, surgery, and survival. Univariate tests and proportional hazards were calculated.
  
  
  RESULTS
  The US uninsurance rate was 14.2%, and the range for the Surveillance, Epidemiology, and End Results counties was 8.3%-24.1%. Overall, patients from lower uninsurance rate counties demonstrated longer median survival. Adjusting for patient characteristics and cancer stage (for each cancer), the patients in the higher uninsurance rate counties demonstrated greater mortality (8%-15% increased risk on proportional hazards). The county uninsurance rate was associated with the stage at diagnosis for all cancers, except pancreatic and esophageal, and was also associated with the likelihood of being recommended for cancer-directed surgery (for all cancers).
  
  
  CONCLUSIONS
  Health insurance coverage at a community level appears to influence survival for patients with cancer. Additional investigations are needed to examine whether individual versus community associations exist and how best to surmount barriers to cancer care.
authors.affiliation: Surgical Outcomes Analysis and Research, Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts.
authors.forename: Jillian K
authors.initials: JK
authors.lastname: Smith
authors.forename: Sing Chau
authors.initials: SC
authors.lastname: Ng
authors.forename: Zheng
authors.initials: Z
authors.lastname: Zhou
authors.forename: James E
authors.initials: JE
authors.lastname: Carroll
authors.forename: Theodore P
authors.initials: TP
authors.lastname: McDade
authors.forename: Shimul A
authors.initials: SA
authors.lastname: Shah
authors.forename: Jennifer F
authors.initials: JF
authors.lastname: Tseng
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D015994:Incidence; D007348:Insurance, Health / Q000706:statistics & numerical data*; D008297:Male; D017057:Medically Uninsured / Q000706:statistics & numerical data*; D009367:Neoplasm Staging / Q000401:mortality; D009369:Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D017063:Outcome Assessment, Health Care; D016016:Proportional Hazards Models; D018426:SEER Program / Q000706:statistics & numerical data; D014481:United States / Q000453:epidemiology
keywords: Cancer-directed surgery; Insurance; Outcomes; Stage at diagnosis; Survival