title: United States Health Policies and Late-stage Breast and colorectal cancer diagnosis: Why such disparities by age?
abstract: BACKGROUND
  Colorectal and breast cancers are the second most common causes of cancer deaths in the US. Population cancer screening rates are suboptimal and many cancers are diagnosed at an advanced stage, which results in increased morbidity and mortality. Younger populations are more likely to be diagnosed at a later stage, and this age disparity is not well understood. We examine the associations between late-stage breast cancer (BC) and colorectal cancer (CRC) diagnoses and multilevel factors, focusing on individual state regulations of insurance and health practitioners, and interactions between such policies and age. We expect state-level regulations are significant predictors of the rates of late-stage diagnosis among younger adults.
  
  
  METHODS
  We included adults of all ages, with BC or CRC diagnosed between 2004 -2009, obtained from a newly available cancer population database covering 98 % of all known new cancer cases. We included personal characteristics, linked with a set of county and state-level predictors based on residence. We applied multilevel models to robustly examine differences in risk of late-stage cancer diagnosis across age groups (defined as age 65+ or < 65), focusing specifically on the effects of state regulatory factors and their interactions with age.
  
  
  RESULTS
  Late stage BC diagnoses range from 24 %-36 %, while CRC diagnoses range from 54 %-60 % of newly diagnosed BC or CRC cases across states. After controlling statistically for many confounding factors at three levels, age < 65 is the largest person-level predictor for CRC, while black race is the largest predictor for BC. State regulations of health markets exhibit significant interactions with age groups.
  
  
  CONCLUSIONS
  The state regulatory climate is an important predictor of late-stage BC and CRC diagnoses, especially among people younger than Medicare eligible age (65). State regulations can enhance the climate of access for younger, less well-insured or uninsured persons who fall outside normative screening guidelines.
authors.affiliation: School of Public Health and Andrew Young School of Policy Studie, Georgia State University, Atlanta, GA, USA, lmobley@gsu.edu.
authors.forename: Lee R
authors.initials: LR
authors.lastname: Mobley
authors.forename: Tzy-Mey
authors.initials: TM
authors.lastname: Kuo