title: Insurance status and risk of cancer mortality among adolescents and young adults.
abstract: BACKGROUND
  Adolescents and young adults with cancer have inferior survival outcomes compared with younger pediatric patients and older adult patients. Lack of insurance may partly explain this disparity. The objective of this study was to identify associations between insurance status and both advanced-stage cancer and cancer-specific mortality.
  
  
  METHODS
  Using the Surveillance, Epidemiology, and End Results (SEER) 18 registries, 57,981 patients ages 15 to 39 years were identified who were diagnosed between 2007 and 2010 and had complete insurance and staging information. Multinomial logistic regression models were used to identify associations between insurance type and disease stage, with the models adjusted for sex, age, and race. Cox proportional hazards models were used to estimate cancer-specific mortality.
  
  
  RESULTS
  Overall, 84% of patients were aged ≥ 25 years, 64% were women, and 79% were privately insured. Compared with patients who had private insurance, those who had nonprivate insurance tended to present with more advanced-stage disease and to die more quickly and more commonly from their cancer. Patients ages 25 to 39 years who had Medicaid coverage or no insurance had 3.2 times and 2.4 times higher odds of having stage IV disease, respectively, than privately insured patients (95% confidence interval [CI], 3.0-3.5 times higher odds and 2.1-2.6 times higher odds, respectively). Among those with stage I/II and III/IV cancers, the risk of death was 2.9 times greater (95% CI, 2.2-3.9 times greater) and 1.7 times greater (95% CI, 1.5-1.9 times greater), respectively, than the risk for privately insured patients. Patients who died from stage III/IV cancers survived at least 2 months longer if they had private insurance.
  
  
  CONCLUSIONS
  Among young adults, insurance status is independently associated with advanced-stage cancer and the risk of death from cancer, even for patients who have low-stage disease. Broader insurance coverage and access to health care may improve some of the disparate outcomes of adolescents and young adults with cancer.
authors.affiliation: Cancer and Blood Disorders Center, Seattle Children's Hospital, Seattle, Washington; Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital Research Foundation, Seattle, Washington.
authors.forename: Abby R
authors.initials: AR
authors.lastname: Rosenberg
authors.forename: Leah
authors.initials: L
authors.lastname: Kroon
authors.forename: Lu
authors.initials: L
authors.lastname: Chen
authors.forename: Christopher I
authors.initials: CI
authors.lastname: Li
authors.forename: Barbara
authors.initials: B
authors.lastname: Jones
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D006801:Humans; D019458:Insurance Coverage / Q000458:organization & administration*; D007348:Insurance, Health / Q000458:organization & administration*; D008297:Male; D009369:Neoplasms / Q000191:economics / Q000401:mortality* / Q000473:pathology; D012189:Retrospective Studies; D012307:Risk Factors; D018426:SEER Program; D014481:United States / Q000453:epidemiology; D055815:Young Adult
keywords: AYA; Affordable Care Act; adolescents; cancer; cancer disparities; health care reform; health insurance; pediatrics; young adults