title: Disparities in the Local Management of Breast Cancer in the US according to Health Insurance Status.
abstract: Although standard practice guidelines for breast cancer are clear, the interplay between insurance and practice patterns for the US is poorly defined. This study was performed to test for associations between patient insurance status and presentation of breast cancer as well as local therapy patterns in the US, via a large national dataset. We queried the NCI Surveillance, Epidemiology, and End Results data base for breast cancer cases diagnosed from 2007 to 2011 in women aged 18-64 with nonmetastatic ductal/lobular cancers, treated surgically. We tested for associations between insurance status (insured/Medicaid/uninsured) and choice of surgical procedure (mastectomy/breast conserving surgery [BCS]), omission of radiotherapy (RT) following BCS, and administration of post-mastectomy radiation (PMRT). There were 129,565 patients with localized breast cancer analyzed. The health insurance classification included insured (84.5%), Medicaid (11.5%), uninsured (2.1%) and unknown (1.9%). Medicaid or uninsured status was associated with large, node positive tumors, black race, and low income. The BCS rate varied by insurance status: insured (52.2%), uninsured (47.7%), and Medicaid (45.2%), p < 0.001. In multivariable analysis, Medicaid insurance remained significantly associated with receipt of mastectomy (OR [95% CI] = 1.07 [1.03-1.11]), while RT was more frequently omitted after BCS in both Medicaid (OR [95% CI] = 1.14 [1.07-1.21]) and uninsured (OR [95% CI] = 1.29 [1.14-1.47]) patients. Insurance status was associated with significant variations in breast cancer care in the US. Although patient choice cannot be determined from this dataset, departure from standard of care is associated with specific types of insurance coverage. Further investigation into the reasons for these departures is strongly suggested.
authors: Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania.
authors: Thomas M
authors: TM
authors: Churilla
authors: Department of Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center, Philadelphia, Pennsylvania.
authors: Brian
authors: B
authors: Egleston
authors: Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania.
authors: Richard
authors: R
authors: Bleicher
authors: Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania.
authors: Yanqun
authors: Y
authors: Dong
authors: Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania.
authors: Joshua
authors: J
authors: Meyer
authors: Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania.
authors: Penny
authors: P
authors: Anderson
mesh_terms: D000293:Adolescent; D000328:Adult; D001943:Breast Neoplasms / Q000601:surgery / Q000628:therapy*; D005260:Female; D054625:Healthcare Disparities; D006801:Humans; D019458:Insurance Coverage; D007348:Insurance, Health; D015412:Mastectomy, Segmental / Q000706:statistics & numerical data; D008484:Medicaid; D017057:Medically Uninsured; D008875:Middle Aged; D012042:Registries; D018426:SEER Program; D014481:United States; D055815:Young Adult
keywords: SEER; breast cancer; insurance; radiation therapy; surgery