title: Disparities in the management and outcome of cervical cancer in the United States according to health insurance status.
abstract: Our study sought to characterize the presentation, local management and outcomes of invasive cervical cancer with regard to patient insurance status.
  
  
  
  We queried the NCI-SEER database for invasive cervical cancer cases in patients aged 18-64 from 2007 to 2011. We analyzed clinical and socioeconomic data with regard insurance status (insured, Medicaid, or uninsured). We tested for associations between patient insurance status and treatment with definitive surgery for FIGO IA2-IB1 patients, and treatment with suboptimal radiation therapy (RT) for FIGO IB2-IVA patients (other than combination external beam and brachytherapy). We evaluated overall and cause specific survival according to insurance status.
  
  
  
  11,714 cases were analyzed: 60% insured, 31% Medicaid, and 9% uninsured. FIGO III/IV stage at presentation was more frequent with Medicaid (40%) and uninsured (42%) compared to insured patients (28%) (p<0.001). For FIGO IA2-IB1 patients, receipt of definitive surgery was inversely associated with uninsured status (OR [95%CI]=0.65 [0.47-0.90], p<0.001) in univariable analysis; however the relationship lost significance after multivariable adjustment. For FIGO IB2-IVA patients, the use of suboptimal RT was associated with uninsured status (OR [95%CI]=1.33 [1.07-1.65], p=0.011) in adjusted analyses. Among all patients, overall mortality was increased with Medicaid (HR [95%CI]=1.16 [1.05-1.28], p=0.003) and uninsured status (HR [95%CI]=1.17 [1.01-1.34], p=0.031) in multivariable analysis. Cancer specific mortality survival trended towards significance in multivariable analyses for both Medicaid (HR [95%CI]=1.11 [1.00-1.24] and uninsured status (HR [95%CI]=1.14 [0.98-1.33]).
  
  
  
  Disparities in cervical cancer treatment with regard to insurance status are apparent in a recent cohort of American patients. Later stage at presentation and differences in management partially account for the inferior prognostic outcomes associated with Medicaid and uninsured status.
authors.affiliation: Departments of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, United States. Electronic address: Thomas.Churilla@fccc.edu.
authors.forename: Thomas
authors.initials: T
authors.lastname: Churilla
authors.affiliation: Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center, Philadelphia, PA 19111, United States.
authors.forename: Brian
authors.initials: B
authors.lastname: Egleston
authors.affiliation: Departments of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, United States.
authors.forename: Yanqun
authors.initials: Y
authors.lastname: Dong
authors.affiliation: Departments of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, United States.
authors.forename: Talha
authors.initials: T
authors.lastname: Shaikh
authors.affiliation: Departments of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, United States.
authors.forename: Colin
authors.initials: C
authors.lastname: Murphy
authors.affiliation: Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, United States.
authors.forename: Gina
authors.initials: G
authors.lastname: Mantia-Smaldone
authors.affiliation: Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, United States.
authors.forename: Christina
authors.initials: C
authors.lastname: Chu
authors.affiliation: Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, United States.
authors.forename: Stephen
authors.initials: S
authors.lastname: Rubin
authors.affiliation: Departments of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, United States.
authors.forename: Penny
authors.initials: P
authors.lastname: Anderson
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D007348:Insurance, Health / Q000706:statistics & numerical data*; D008484:Medicaid / Q000706:statistics & numerical data; D008875:Middle Aged; D009367:Neoplasm Staging; D018426:SEER Program; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D002583:Uterine Cervical Neoplasms / Q000191:economics / Q000401:mortality* / Q000473:pathology / Q000628:therapy*; D055815:Young Adult