From Our 2007 Archives

Uninsured More Likely to Die From Cancer Following Diagnosis

By Steven Reinberg
HealthDay Reporter

THURSDAY, Dec. 20 (HealthDay News) -- People diagnosed with cancer who don't have health insurance are more likely to die because they are less likely to get screening tests and so are typically diagnosed with advanced disease, a new study from the American Cancer Society finds.

The finding proffers strong evidence that differences in cancer survival are directly related to lack of access to health care.

"If you are uninsured, and you are diagnosed with cancer, you have a 60 percent greater chance of dying from cancer than if you were insured and diagnosed with cancer," said Dr. Otis Brawley, chief medical officer at the cancer society.

"There is not a cohort of insured and a cohort of uninsured cancer patients that have the same five-year survival," Brawley added. "It's always the uninsured who do worse."

Part of the problem is that uninsured people don't have access to screenings, Brawley said. "But part of it is that uninsured people don't have access to the best doctors or have access to good doctors who are overwhelmed. The end result is the quality of care the poor folks get is not as good as the quality of care of the wealthier or the insured," he said.

There are also people who are underinsured, Brawley said. While these people have access to care, high co-pays and deductibles make the care unaffordable, particularly high-priced chemotherapy drugs, he noted.

"Where it becomes frightening and morally reprehensible is people who have significant pain and can't get narcotics and other pain medications they need, because they can't afford them," Brawley said.

People don't realize they are underinsured until after they have gotten sick, Brawley said. "There are a substantial number of Americans who don't realize they are a cancer diagnosis away from economic disaster," he noted.

The study, in the January/February issue of CA: A Cancer Journal for Clinicians, used data from the National Cancer Database, which is the only national registry that collects data on patient insurance.

The report is an overview of systems of health insurance in the United States. It has data on the association between health insurance, screening, stage at diagnosis, and survival for breast and colorectal cancer.

The link between access to care and cancer outcomes is particularly striking for cancers that can be prevented or found early by screening and for which there are effective treatments, including breast and colorectal cancer.

Only about 38.1 percent of uninsured women aged 40 to 64 have had a mammogram in the past two years, compared with 74.5 percent of insured women. In addition, 20 percent to 30 percent of uninsured women are diagnosed with late-stage breast cancer, compared with 10 percent to 15 percent of women with private insurance, according to the study.

Uninsured women are less likely to be diagnosed with early breast cancer than women who are privately insured. This disparity was greatest among white women, where almost 50 percent of those with private insurance were diagnosed with early-stage cancer, compared with fewer than 35 percent of uninsured white women.

Moreover, 89 percent of insured white women were living five years after breast cancer diagnosis compared with 76 percent of uninsured white women. For black women, five-year survival rates are 81 percent for those with private insurance and 65 percent for uninsured women.

For men and women aged 50 to 64 who have private insurance, 48.3 percent were screened for colorectal cancer in the past 10 years compared with fewer than 18.8 percent of the uninsured.

In addition, uninsured patients are more likely than those with private insurance to be diagnosed with stage IV colorectal cancer and less likely to be diagnosed with stage I colorectal cancer, the researchers found.

For whites, 66 percent of insured patients survive colorectal cancer for five years, compared with 50 percent of those without insurance. For blacks, five-year survival rates are 41 percent among the uninsured compared with 60 percent among privately insured patients.

Additional findings in the study include:

  • Uninsured women were less likely to have a Pap test in the past three years than insured women (68 percent vs. 87.9 percent).
  • Among insured men, 37.1 percent had a prostate specific antigen test, compared with 14 percent of uninsured men.
  • People aged 18 to 24 have the highest probability of being uninsured.
  • Lower-income people are more likely to be uninsured.
  • Blacks, Hispanics, Asian American/Pacific Islanders, and American Indian/Alaska Natives are more likely to be uninsured than whites.
  • Of those without insurance, 53.6 percent have no usual source of health care.
  • The uninsured are more likely to delay care, not receive care, and not obtain prescription drugs because of costs.
  • Among people who saw a health-care provider, those without insurance were less likely to be advised to quit smoking or lose weight.

Brawley noted that while some of the uninsured qualify for Medicaid, coverage doesn't begin until the cancer has been diagnosed.

"You have someone who is uninsured and poor -- gets none of the screenings, gets none of the early detection opportunities -- when they finally go to the doctor, it's because they are so sick, they can no longer go to work, or their family is forcing them to go to the emergency room," Brawley said. "What you have is someone who a year ago we could, relatively cheaply, fix, maybe even cure, but now that they have ignored their symptoms, it's no longer fixable, we are going to treat them, but the treatment is going to be very expensive."

The remedy to the problem is "making sure that everyone who wants health insurance can get affordable health insurance," Brawley said. "In this country, we need to have an open conversation about this issue."

One expert thinks this study highlights the need for a health insurance program that covers everyone.

"Sadly, many Americans must face the challenges of cancer with no insurance coverage, or with Medicaid, which is often grossly inadequate as coverage," said Dr. Steffie Woolhandler, an associate professor of medicine at Harvard Medical School and a co-founder of Physicians for a National Health Program.

For these cancer patients, diagnosis is delayed and survival is shortened, Woolhandler said. "We need nonprofit national health insurance to be sure that everyone gets the health care they need, particularly people with cancer."

SOURCES: Otis Brawley, M.D., chief medical officer, American Cancer Society, Atlanta; Steffie Woolhandler, M.D., associate professor, medicine, Harvard Medical School, Boston, and co-founder, Physicians for a National Health Program; January/February 2008, CA: A Cancer Journal for Clinicians

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