title: Effects of payer status on breast cancer survival: a retrospective study.
abstract: BACKGROUND
  Breast cancer outcomes are influenced by multiple factors including access to care, and payer status is a recognized barrier to treatment access. To further define the influence of payer status on outcome, the National Cancer Data Base data from 1998-2006 was analyzed.
  
  
  METHODS
  Data was analyzed from 976,178 female patients diagnosed with breast cancer registered in the National Cancer Data Base. Overall survival was the primary outcome variable while payer status was the primary predictor variable. Secondary predictor variables included stage, age, race, Charlson Comorbidity index, income, education, distance travelled, cancer program, diagnosing/treating facility, and treatment delay. Multivariate Cox regression was used to investigate the effect of payer status on overall survival while adjusting for secondary predictive factors.
  
  
  RESULTS
  Uninsured (28.68%) and Medicaid (28.0%) patients had a higher percentage of patients presenting with stage III and stage IV cancer at diagnosis. In multivariate analysis, after adjusting for secondary predictor variables, payer status was a statistically significant predictor of survival. Patients with private, unknown, or Medicare status showed a decreased risk of dying compared to uninsured, with a decrease of 36%, 22%, and 15% respectively. However, Medicaid patients had an increased risk of 11% compared to uninsured. The direct adjusted median overall survival was 14.92, 14.76, 14.56, 13.64, and 12.84 years for payer status of private, unknown, Medicare, uninsured, and Medicaid respectively.
  
  
  CONCLUSIONS
  We observed that patients with no insurance or Medicaid were most likely to be diagnosed at stage III and IV. Payer status showed a statistically significant relationship with overall survival. This remained true after adjusting for other predictive factors. Patients with no insurance or Medicaid had higher mortality.
authors.affiliation: Department of Medicine & Feist-Weiller Cancer Center, LSU Health Shreveport, 1501 Kings Hwy, Shreveport, LA, 71103, USA. rshi@lsuhsc.edu.
authors.forename: Runhua
authors.initials: R
authors.lastname: Shi
authors.affiliation: Feist-Weiller Cancer Center, LSU Health Shreveport, 1501 Kings Hwy, Shreveport, LA, 71103, USA. htayl2@lsuhsc.edu.
authors.forename: Hannah
authors.initials: H
authors.lastname: Taylor
authors.affiliation: Department of Medicine & Feist-Weiller Cancer Center, LSU Health Shreveport, 1501 Kings Hwy, Shreveport, LA, 71103, USA. jmclar@lsuhsc.edu.
authors.forename: Jerry
authors.initials: J
authors.lastname: McLarty
authors.affiliation: Department of Medicine & Feist-Weiller Cancer Center, LSU Health Shreveport, 1501 Kings Hwy, Shreveport, LA, 71103, USA. lliu1@lsuhsc.edu.
authors.forename: Lihong
authors.initials: L
authors.lastname: Liu
authors.affiliation: Department of Medicine & Feist-Weiller Cancer Center, LSU Health Shreveport, 1501 Kings Hwy, Shreveport, LA, 71103, USA. gmills@lsuhsc.edu.
authors.forename: Glenn
authors.initials: G
authors.lastname: Mills
authors.affiliation: Department of Medicine & Feist-Weiller Cancer Center, LSU Health Shreveport, 1501 Kings Hwy, Shreveport, LA, 71103, USA. gburto@lsuhsc.edu.
authors.forename: Gary
authors.initials: G
authors.lastname: Burton
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000453:epidemiology* / Q000401:mortality / Q000473:pathology; D016208:Databases, Factual; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D007348:Insurance, Health; D008875:Middle Aged; D009367:Neoplasm Staging; D063868:Patient Outcome Assessment; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology