title: Disparities in stage at diagnosis, treatment, and survival in nonelderly adult patients with cancer according to insurance status.
abstract: OBJECTIVE
  The purpose of this study was to determine the association of insurance status with disease stage at presentation, treatment, and survival among the top 10 most deadly cancers using the SEER database.
  
  
  METHODS
  A total of 473,722 patients age 18 to 64 years who were diagnosed with one of the 10 most deadly cancers in the SEER database from 2007 to 2010 were analyzed. A Cox proportional hazards model was used for multivariable analyses to assess the effect of patient and tumor characteristics on cause-specific death.
  
  
  RESULTS
  Overall, patients with non-Medicaid insurance were less likely to present with distant disease (16.9%) than those with Medicaid coverage (29.1%) or without insurance coverage (34.7%; P < .001). Patients with non-Medicaid insurance were more likely to receive cancer-directed surgery and/or radiation therapy (79.6%) compared with those with Medicaid coverage (67.9%) or without insurance coverage (62.1%; P < .001). In a Cox regression that adjusted for age, race, sex, marital status, residence, percent of county below federal poverty level, site, stage, and receipt of cancer-directed surgery and/or radiation therapy, patients were more likely to die as a result of their disease if they had Medicaid coverage (hazard ratio [HR], 1.44; 95% CI, 1.41 to 1.47; P < .001) or no insurance (HR, 1.47; 95% CI, 1.42 to 1.51; P < .001) compared with non-Medicaid insurance.
  
  
  CONCLUSIONS
  Among patients with the 10 most deadly cancers, those with Medicaid coverage or without insurance were more likely to present with advanced disease, were less likely to receive cancer-directed surgery and/or radiation therapy, and experienced worse survival.
authors.affiliation: Gary V. Walker, B. Ashleigh Guadagnolo, Karen E. Hoffman, Benjamin D. Smith, Pamela K. Allen, and Usama Mahmood, University of Texas MD Anderson Cancer Center; Gary V. Walker, University of Texas Health Science Center School of Biomedical Informatics; Stephen R. Grant, Baylor College of Medicine, Houston, TX; and Matthew Koshy, University of Chicago, Chicago, IL.
authors.forename: Gary V
authors.initials: GV
authors.lastname: Walker
authors.affiliation: Gary V. Walker, B. Ashleigh Guadagnolo, Karen E. Hoffman, Benjamin D. Smith, Pamela K. Allen, and Usama Mahmood, University of Texas MD Anderson Cancer Center; Gary V. Walker, University of Texas Health Science Center School of Biomedical Informatics; Stephen R. Grant, Baylor College of Medicine, Houston, TX; and Matthew Koshy, University of Chicago, Chicago, IL.
authors.forename: Stephen R
authors.initials: SR
authors.lastname: Grant
authors.affiliation: Gary V. Walker, B. Ashleigh Guadagnolo, Karen E. Hoffman, Benjamin D. Smith, Pamela K. Allen, and Usama Mahmood, University of Texas MD Anderson Cancer Center; Gary V. Walker, University of Texas Health Science Center School of Biomedical Informatics; Stephen R. Grant, Baylor College of Medicine, Houston, TX; and Matthew Koshy, University of Chicago, Chicago, IL.
authors.forename: B Ashleigh
authors.initials: BA
authors.lastname: Guadagnolo
authors.affiliation: Gary V. Walker, B. Ashleigh Guadagnolo, Karen E. Hoffman, Benjamin D. Smith, Pamela K. Allen, and Usama Mahmood, University of Texas MD Anderson Cancer Center; Gary V. Walker, University of Texas Health Science Center School of Biomedical Informatics; Stephen R. Grant, Baylor College of Medicine, Houston, TX; and Matthew Koshy, University of Chicago, Chicago, IL.
authors.forename: Karen E
authors.initials: KE
authors.lastname: Hoffman
authors.affiliation: Gary V. Walker, B. Ashleigh Guadagnolo, Karen E. Hoffman, Benjamin D. Smith, Pamela K. Allen, and Usama Mahmood, University of Texas MD Anderson Cancer Center; Gary V. Walker, University of Texas Health Science Center School of Biomedical Informatics; Stephen R. Grant, Baylor College of Medicine, Houston, TX; and Matthew Koshy, University of Chicago, Chicago, IL.
authors.forename: Benjamin D
authors.initials: BD
authors.lastname: Smith
authors.affiliation: Gary V. Walker, B. Ashleigh Guadagnolo, Karen E. Hoffman, Benjamin D. Smith, Pamela K. Allen, and Usama Mahmood, University of Texas MD Anderson Cancer Center; Gary V. Walker, University of Texas Health Science Center School of Biomedical Informatics; Stephen R. Grant, Baylor College of Medicine, Houston, TX; and Matthew Koshy, University of Chicago, Chicago, IL.
authors.forename: Matthew
authors.initials: M
authors.lastname: Koshy
authors.affiliation: Gary V. Walker, B. Ashleigh Guadagnolo, Karen E. Hoffman, Benjamin D. Smith, Pamela K. Allen, and Usama Mahmood, University of Texas MD Anderson Cancer Center; Gary V. Walker, University of Texas Health Science Center School of Biomedical Informatics; Stephen R. Grant, Baylor College of Medicine, Houston, TX; and Matthew Koshy, University of Chicago, Chicago, IL.
authors.forename: Pamela K
authors.initials: PK
authors.lastname: Allen
authors.affiliation: Gary V. Walker, B. Ashleigh Guadagnolo, Karen E. Hoffman, Benjamin D. Smith, Pamela K. Allen, and Usama Mahmood, University of Texas MD Anderson Cancer Center; Gary V. Walker, University of Texas Health Science Center School of Biomedical Informatics; Stephen R. Grant, Baylor College of Medicine, Houston, TX; and Matthew Koshy, University of Chicago, Chicago, IL. umahmood@mdanderson.org.
authors.forename: Usama
authors.initials: U
authors.lastname: Mahmood
mesh_terms: D000293:Adolescent; D000328:Adult; D054625:Healthcare Disparities / Q000191:economics*; D006801:Humans; D019458:Insurance Coverage / Q000191:economics*; D007348:Insurance, Health / Q000191:economics*; D053208:Kaplan-Meier Estimate; D008484:Medicaid / Q000191:economics; D008875:Middle Aged; D009367:Neoplasm Staging; D009369:Neoplasms / Q000473:pathology / Q000628:therapy*; D018426:SEER Program / Q000706:statistics & numerical data; D014481:United States; D055815:Young Adult
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