title: Health Insurance Affects Head and Neck Cancer Treatment Patterns and Outcomes.
abstract: OBJECTIVE
  The purpose of this study is to examine the effect of insurance coverage on stage of presentation, treatment, and survival of head and neck cancer (HNC).
  
  
  METHODS
  A retrospective study was conducted using the Surveillance, Epidemiology, and End Results (SEER) program to identify patients diagnosed with HNC. The primary variable of interest was insurance analyzed as a dichotomous variable: Patients were considered uninsured if they were classified as "uninsured" by SEER, whereas patients were considered insured if they were defined by SEER as "any Medicaid," "insured," or "insured/no specifics." The outcomes of interest were cancer stage at presentation (M0 vs M1), receipt of definitive treatment, and HNC-specific mortality (HNCSM). Multivariable logistic regression modeled the association between insurance status and stage at presentation, as well as between insurance status and receipt of definitive treatment, whereas HNCSM was modeled using Fine and Gray competing risks. Sensitivity logistic regression analysis was used to determine whether observed interactions remained significant by insurance type (privately insured, Medicaid, and uninsured).
  
  
  RESULTS
  Patients without medical insurance were more likely to present with metastatic cancer (adjusted odds ratio, 1.60; P < .001), were more likely to not receive definitive treatment (adjusted odds ratio, 1.64; P < .001), and had a higher risk of HNCSM (adjusted hazard ratio, 1.20; P = .002). Sensitivity analyses showed that when results were stratified by insurance type, significant interactions remained for uninsured patients and patients with Medicaid.
  
  
  CONCLUSIONS
  Uninsured patients and patients with Medicaid are more likely to present with metastatic disease, are more likely to not be treated definitively, and are at a higher risk of HNCSM. The treatment gap between Medicaid and private insurance observed in this study should serve as an immediate policy target for health care reform.
authors: Resident, Department of Oral and Maxillofacial Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA. Electronic address: gino.inverso@uphs.upenn.edu.
authors: Gino
authors: G
authors: Inverso
authors: Resident, Harvard Radiation Oncology Program, Boston, MA.
authors: Brandon A
authors: BA
authors: Mahal
authors: Instructor, Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA.
authors: Ayal A
authors: AA
authors: Aizer
authors: Dean, Harvard School of Dental Medicine, and Walter C. Guralnick Distinguished Professor of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA.
authors: R Bruce
authors: RB
authors: Donoff
authors: Associate Professor, Harvard School of Dental Medicine, and Director, Center for Applied Clinical Investigation, Massachusetts General Hospital, Boston, MA.
authors: Sung-Kiang
authors: SK
authors: Chuang
mesh_terms: D005260:Female; D006258:Head and Neck Neoplasms / Q000191:economics / Q000628:therapy*; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data; D007348:Insurance, Health / Q000706:statistics & numerical data*; D008297:Male; D008484:Medicaid / Q000706:statistics & numerical data; D017057:Medically Uninsured / Q000706:statistics & numerical data; D008875:Middle Aged; D012189:Retrospective Studies; D018426:SEER Program; D016019:Survival Analysis; D016896:Treatment Outcome; D014481:United States