Insurance Coverage Explains Half of Racial Disparity in Colorectal Cancer Survival
By Scott Baltic
NEW YORK (Reuters Health) - Differences in health insurance coverage account for about half of the substantial disparity in survival between black and white patients with colorectal cancer (CRC), according to a U.S. study.
“The magnitude of black versus white survival disparity in colorectal cancer contributed by insurance coverage difference was surprising. Our study showed that affordable health insurance coverage for all populations could substantially reduce differences in survival times of black versus white patients with colorectal cancer,” corresponding author Dr. Helmneh Sineshaw, director of Treatment Patterns and Outcomes Research for the American Cancer Society, Atlanta, told Reuters Health by email.
The researchers analyzed data, from the hospital-based National Cancer Database of the American College of Surgeons and the American Cancer Society, on 199,098 non-Hispanic patients (ages 18 to 64) diagnosed from 2004 to 2012 with single or first primary invasive CRC. Of the patients in the cohort, 17% were black and the rest were white. The findings were reported online November 13 in Gastroenterology.
The black patients were likelier to be younger and female - and more likely to present with stage 4 disease, right-sided colon cancer, and a comorbidity score of at least 2. Blacks also were less likely than whites to receive chemotherapy, radiation treatment, or rectal cancer surgery.
Absolute 5-year survival rates were 57.3% for blacks and 66.5% for whites.
To analyze the race-related disparities, the researchers categorized the white patients into five partially overlapping subgroups: matched with black patients for demographics (age, sex, diagnosis year, and U.S. census division); demographics plus insurance status (uninsured, Medicaid, Medicare, or private); those two factors plus comorbidity score; those three factors plus tumor characteristics; and, finally, those four factors plus treatment.
Treatment differences were not affected by demographic matching. However, receipt of rectal cancer surgery was affected by insurance matching, and receipt of chemotherapy and radiation were affected by tumor characteristics matching.
The absolute survival difference by race (9.2%) remained unchanged after demographic matching - but it declined to 4.9% after insurance matching, to 4.7% after comorbidity matching, and to 2.3% after tumor-characteristics matching. Subsequent treatment matching did not reduce the survival difference any further.
According to the authors, the unexplained 2.3% of the disparity might be attributable to factors their study did not measure, such as differences in completion or quality of treatment or in socioeconomic indicators other than insurance.
In analyses of individual contributory factors, insurance coverage alone accounted for 50% of the racial disparity.
Citing prior research, the authors write, “Certainly, lack of health insurance coverage for patients could greatly impact access to timely diagnosis and treatment, with lower receipt of screening tests and follow-up for abnormal test results. Compared with privately-insured patients, uninsured patients were less likely to have a primary source of care for preventive services, more likely to be diagnosed with advanced stage diseases, less likely to receive standard of care, and more likely to die of their diseases.”
“Our findings reinforce the importance of equitable health insurance coverage to mitigate the black-white survival disparity in 18-64 years old CRC patients,” they conclude.
By focusing on insurance coverage, this study is “very timely,” Dr. Karen Winkfield, director of the Office of Cancer Health Equity at the Comprehensive Cancer Center, Wake Forest Baptist Health, Winston-Salem, North Carolina, told Reuters Health by telephone.
Much of what this report covers, she added, is already known, such as the fact that CRC incidence in African-Americans is higher than in the general U.S. population and that African-Americans typically get CRC earlier in life.
These differences could be tied to lifestyle factors such as high rates of obesity, high-fat diets, and smoking, but are probably not genetic, said Dr. Winkfield, who also is a former chair of the American Society of Clinical Oncology’s Health Disparities Committee. Whole-genome sequencing so far does not suggest purely genetic reasons, she added, though epigenetic factors “can go back generations.”
A key question, she said, is “how do we standardize cancer care for the entire nation?”
Being uninsured or underinsured affects the availability of testing, in addition to which, Dr. Winkfield said, insurers might reimburse differently for screening versus diagnostic tests. A positive result on a (screening) fecal occult blood test would typically be followed by an order for a colonoscopy, which, as a diagnostic test, might involve a higher co-payment.
“Coinsurance costs are prohibitive for some populations . . . . These games are being played with people’s lives,” she said, adding that disadvantaged populations can face “financial toxicity” beyond their health concerns.
The bottom line, according to Dr. Winkfield: “Insurance matters.”
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