title: Gastric cancer survival and affiliation to health insurance in a middle-income setting.
abstract: OBJECTIVE
  To investigate whether health insurance affiliation and socioeconomic deprivation is associated with overall cause survival from gastric cancer in a middle-income country.
  
  
  METHODS
  All patients resident in the Bucaramanga metropolitan area (Colombia) diagnosed with gastric cancer between 2003 and 2009 (n=1039), identified in the population-based cancer registry, were followed for vital status until 31/12/2013. Kaplan-Meier models provided crude survival estimates by health insurance regime (HIR) and social stratum (SS). Multivariate Cox-proportional hazard models adjusting HIR and SS for sex, age and tumor grade, were performed.
  
  
  RESULTS
  Overall 1 and 5 year survival proportions were 32.4% and 11.0%, respectively, varying from 49.3% and 15.8% for patients affiliated to the most generous HIR to 12.9% and 5.3% for unaffiliated patients, and from 41.4% and 20.7% for patients in the highest SS, versus 27.1% and 7.4% for the lowest SS. The multivariate analyses showed type of HIR as well as SS to remain independently associated with survival, with an 11% improvement in survival for each increase in SS subgroup (HR 0.89 (95% CI 0.83; 0.96), and with worse survival in the subsidized (least generous) HIR and unaffiliated patients compared to the contributory HIR (HR subsidized 1.20 (95% CI 1.00; 1.43) and HR not affiliated 2.03 (95% CI 1.48; 2.78)). Of the non-affiliated patients, 60% had died at the time of diagnosis, versus 4-14% of affiliated patients (p<0.0005).
  
  
  CONCLUSIONS
  Despite the 'universal' health insurance system, large socioeconomic differences in gastric cancer survival exist in Colombia. Both social stratum and access to effective diagnostic and curative care strongly influence survival.
authors: Esther de Vries, David Forman-International Agency for Research on Cancer, Section of Cancer Information, Lyon Cedex 08 69372, France; Esther de Vries, Constanza Pardo-Instituto Nacional de Cancerología, Cancer Surveillance and Epidemiology group, Bogotá, Cundinamarca, Colombia; Esther de Vries-Erasmus MC University Medical Center, Department of Public Health, Rotterdam 3000 CA, Zuid-Holland, The Netherlands. Electronic address: edevries@cancer.gov.co.
authors: Esther
authors: E
authors: de Vries
authors: Claudia Uribe-Universidad Autónoma de Bucaramanga, Grupo Estudio Genético de Enfermedades Complejas, Bucaramanga, Santander, Colombia.
authors: Claudia
authors: C
authors: Uribe
authors: Esther de Vries, Constanza Pardo-Instituto Nacional de Cancerología, Cancer Surveillance and Epidemiology group, Bogotá, Cundinamarca, Colombia.
authors: Constanza
authors: C
authors: Pardo
authors: Esther de Vries-Erasmus MC University Medical Center, Department of Public Health, Rotterdam 3000 CA, Zuid-Holland, The Netherlands; Valery Lemmens, Comprehensive Cancer Center, The Netherlands, Schuttersveld 2, Leiden, The Netherlands.
authors: Valery
authors: V
authors: Lemmens
authors: Ellen van de Poel-Erasmus University Rotterdam, Institute of Health Policy and Management, Rotterdam 3000 CA, Zuid-Holland, The Netherlands.
authors: Ellen
authors: E
authors: Van de Poel
authors: Esther de Vries, David Forman-International Agency for Research on Cancer, Section of Cancer Information, Lyon Cedex 08 69372, France.
authors: David
authors: D
authors: Forman
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D003105:Colombia / Q000453:epidemiology; D005260:Female; D006297:Health Services Accessibility / Q000191:economics*; D054625:Healthcare Disparities / Q000191:economics; D006801:Humans; D007223:Infant; D007348:Insurance, Health / Q000706:statistics & numerical data*; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016016:Proportional Hazards Models; D012042:Registries; D012959:Socioeconomic Factors; D013274:Stomach Neoplasms / Q000191:economics / Q000453:epidemiology*; D055815:Young Adult
keywords: Disparities; Gastric cancer; Health insurance; Incidence; Middle-income countries; Socioeconomic status; Survival