title: The association between insurance status and prostate cancer outcomes: implications for the Affordable Care Act.
abstract: BACKGROUND
  The Affordable Care Act (ACA) aims to expand health insurance coverage to over 30 million previously uninsured Americans. To help evaluate the potential impact of the ACA on prostate cancer care, we examined the associations between insurance coverage and prostate cancer outcomes among men <65 years old who are not yet eligible for Medicare.
  
  
  METHODS
  The Surveillance, Epidemiology and End Results Program was used to identify 85 203 men aged <65 years diagnosed with prostate cancer from 2007 to 2010. Multivariable logistic regression modeled the association between insurance status and stage at presentation. Among men with high-risk disease, the associations between insurance status and receipt of definitive therapy, prostate cancer-specific mortality (PCSM) and all-cause mortality were determined using multivariable logistic, Fine and Gray competing-risks and Cox regression models, respectively.
  
  
  RESULTS
  Uninsured patients were more likely to be non-white and come from regions of rural residence, lower median household income and lower education level (P<0.001 for all cases). Insured men were less likely to present with metastatic disease (adjusted odds ratio (AOR) 0.23; 95% confidence interval (CI) 0.20-0.27; P<0.001). Among men with high-risk disease, insured men were more likely to receive definitive treatment (AOR 2.29; 95% CI 1.81-2.89; P<0.001), and had decreased PCSM (adjusted hazard ratio 0.56; 95% CI 0.31-0.98; P=0.04) and all-cause mortality (adjusted hazard ratio 0.60; 0.39-0.91; P=0.01).
  
  
  CONCLUSIONS
  Insured men with prostate cancer are less likely to present with metastatic disease, more likely to be treated if they develop high-risk disease and are more likely to survive their cancer, suggesting that expanding health coverage under the ACA may significantly improve outcomes for men with prostate cancer who are not yet eligible for Medicare.
authors: Harvard Medical School, Boston, MA, USA.
authors: B A
authors: BA
authors: Mahal
authors: Harvard Radiation Oncology Program, Boston, MA, USA.
authors: A A
authors: AA
authors: Aizer
authors: Harvard Medical School, Boston, MA, USA.
authors: D R
authors: DR
authors: Ziehr
authors: Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors: A S
authors: AS
authors: Hyatt
authors: Harvard Medical School, Boston, MA, USA.
authors: C
authors: C
authors: Lago-Hernandez
authors: Harvard School of Public Health, Boston, MA, USA.
authors: Y-W
authors: YW
authors: Chen
authors: Department of Medical Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors: T K
authors: TK
authors: Choueiri
authors: Department of Urology, UCLA Medical Center, Los Angeles, CA, USA.
authors: J C
authors: JC
authors: Hu
authors: Department of Medical Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors: C J
authors: CJ
authors: Sweeney
authors: Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors: C J
authors: CJ
authors: Beard
authors: Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors: A V
authors: AV
authors: D'Amico
authors: Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors: N E
authors: NE
authors: Martin
authors: Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors: Q-D
authors: QD
authors: Trinh
authors: Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors: P L
authors: PL
authors: Nguyen
mesh_terms: D000367:Age Factors; D006801:Humans; D015994:Incidence; D019458:Insurance Coverage; D007348:Insurance, Health; D008297:Male; D008875:Middle Aged; D009026:Mortality; D063868:Patient Outcome Assessment; D058991:Patient Protection and Affordable Care Act; D011159:Population Surveillance; D011471:Prostatic Neoplasms / Q000175:diagnosis / Q000453:epidemiology*; D012307:Risk Factors; D018426:SEER Program; D014481:United States / Q000453:epidemiology / Q000208:ethnology