If you had any doubts that health insurance makes a difference when it comes to survival from cancer, then articles released today in the medical journal Cancer should erase the question from your mind.
In two research papers and an editorial, investigators from the American Cancer Society and the Society’s President make it very clear that if you don’t have adequate insurance, the odds are considerable that as far as breast and head and neck cancer are concerned, you are more likely to be diagnosed with your cancer at a later stage when treatment options are either more limited or more toxic, and the odds for survival are substantially less.
With more than 46 million Americans uninsured, these reports are certain to add fuel to the growing debate over the state of our health care system in the
In the first report, the researchers looked at information regarding health insurance and other demographic factors in over 553,000 women diagnosed with breast cancer from 1998 to 2003.
The source of their information was from over 1400 hospitals that participate in a program called the National Cancer Database, sponsored jointly by the American Cancer Society and the
This program is unique because, unlike other state and national cancer surveillance and registry programs, this one collects information regarding insurance among other patient-related characteristics.
The authors examined the stage of breast cancer diagnosis as it related to the type of insurance the patient had at the time of diagnosis. They broke the insurance categories down into several types including Medicaid, Medicare, uninsured, and private insurance.
They also looked at race, age, and income and education as determined by the zip-codes where the women lived.
They found that in this large sample of women, 55% had private health insurance, 37% were over 65 and had Medicare, 2% of the women were under 65 and had Medicare, 2% had no insurance, and 3% had Medicaid.
When the information was examined by stage at diagnosis (with stage I being limited to the breast through stage IV which means advanced disease spread to other parts of the body), 55% were stage I, 36% were stage II, and 9 % had advanced disease with stage III or stage IV.
So what was the impact of insurance type (or lack of insurance) on the stage at diagnosis?
Remember that this is a very important question, because women who present with stage I disease have a 5 year survival from breast cancer that is now about 98%, while women who present with stage IV disease have about a 26% 5 year survival.
When compared to women with private health insurance, a woman with Medicaid or no insurance had about a 50% greater chance of having stage II breast cancer. With Medicare, the odds of having stage II disease were actually about 10% LESS than women with private insurance.
When looking at women diagnosed with the most advanced stages of breast cancer (3 and 4), the chances were about 2 ½ times greater that a woman with Medicaid or no insurance would present with advanced disease, when compared to a woman with private health insurance. (In this comparison, women age 65 and over with Medicare had about the same chances of stage III/IV disease at diagnosis when compared to women with private health insurance.)
The researchers also found that race, income and education played roles in the stage of diagnosis.
Black women had about a 52% greater chance of being diagnosed at Stage II and 85% greater chance of being diagnosed with advanced (III/IV) disease compared to whites. Hispanic women also had an increased likelihood of being diagnosed with more advanced disease compared with whites.
Areas with a lower proportion of high school graduates also had more advanced stage at diagnosis of breast cancer.
The researchers noted in their introduction that when these cancers are diagnosed early, they can be treated with limited impact on routine function. But, when diagnosed at a more advanced stage, the impact on quality of life and survival can be substantial.
These investigators used the same database as they used in the previous paper. They studied about 40,500 patients diagnosed from 1996-2003.
And, not unexpectedly, the results were similar to those found in the breast cancer study.
Patients who were uninsured or had Medicaid had a 37% greater chance of presenting with more advanced disease compared to patients with private health insurance.
They also found that men, people age 52 or older, or residence in an area with a low proportion of high school graduates also had greater odds of presenting with more advanced head and neck cancer.
Unlike the previous study on breast cancer, patients who were 65 years of age or older and on Medicare did not have more frequent early stage presentation than patients with private health insurance (the chances of presenting with early stage disease were similar in both groups).
The real question is what does all this mean, especially in this time of heightened concern about health insurance costs and availability?
Certainly, the presidential candidates are aware of the issue—although no breathtaking plans have yet emerged from any of the many candidates in both parties.
In the editorial that accompanied these scientific reports, the current President of the American Cancer Society, Dr. Richard Wender, places the issue squarely on the table.
Dr. Wender points out that the Society has adopted guiding principles to evaluate health insurance reform proposals that may be forthcoming now or in the future, with an emphasis on looking at these proposals “through the cancer lens.”
We know that without health insurance, prevention and early detection of cancer is a wish and not a fact.
We know that without adequate health insurance, having an identified source of primary care is also a wish and not a fact.
We know that without adequate health insurance, timely treatment for cancer is a wish and not a fact.
In the editorial, Dr. Wender reports on the experience of the American Cancer Society’s national call center (which, by the way, can be reached at 800-ACS-2345 24 hours a day, seven days a week).
He notes that the Society is unable to provide assistance to about 30% of the callers who need help with finance and insurance problems.
Of those who had options, according to his editorial, 70% found the options were either unaffordable or inadequate for their medical needs.
As stated by Dr. Wender, “Our inability to help these individuals obtain and maintain affordable coverage is tragic. The stories of those with inadequate insurance should add another dimension to the health care reform debates.”
I have written often in this blog about the cost of our miracles.
But there clearly is another aspect to cancer care in this country, and that is the basic “blocking and tackling” that needs to be done to ensure that every person in this country has the opportunity to have their cancer diagnosed at an early stage, when treatment is least disfiguring and disruptive and has the best opportunity for cure.
These studies clearly point out the need for us to move forward on this issue, and address the needs of millions of our fellow citizens.
Forget about the miracles for a moment. We clearly need to be thinking about the fundamentals.
Maybe if we got the fundamentals right, that would be the greatest miracle of all.