The Atlanta Journal-Constitution
Monday 18 February 2008
Cancer patients with private insurance are much more likely to be diagnosed early, giving them a greater chance of long-term survival, a sweeping study by the Atlanta-based American Cancer Society shows.
Conversely, uninsured Americans and those with Medicaid are much more likely to have advanced forms of the most common cancers by the time they seek treatment.
For the patients, the disparity can result in decades of lost life. For the health care system, it costs millions of dollars of added medical care, physicians say.
Researchers examined the records of more than 3.5 million American adult patients with 12 types of cancer diagnosed between 1998 and 2004 for a study to be published today in the British journal The Lancet Oncology. The records were collected by the National Cancer Database, a registry with information from about 1,430 hospitals.
The correlation between insurance status and stage of cancer was especially noticeable in colon, breast and prostate cancer, which frequently can be diagnosed early by routine screening, and in diseases such as lung and bladder cancer, which are often caught when patients seek treatment for early symptoms.
The reason seems simple, said Elizabeth Ward, director of surveillance research for the Cancer Society. Patients with insurance are much more likely to have regular screening and physical examinations.
"If you're uninsured, you're about half as likely to get mammography and colonoscopy as if you're insured," she said.
Disparities in diagnosis by insurance status were less pronounced in pancreatic and ovarian cancer, which are rarely diagnosed in anyone until the later stages.
The results tell researchers "that the health care safety net is fairly thin," said Ward. "If you don't have health insurance, it's pretty difficult in some instances to find a source of medical care."
But the study also found that, regardless of insurance coverage, African-American patients were more likely to be diagnosed with some cancers at late stages than white Americans.
That, said Ward, indicates that "health insurance and access to care is not the only barrier" to diagnosis and treatment.
Even when a safety net is in place - - such as the Grady Health System for indigent patients in Fulton and DeKalb counties - - poorer patients are less likely to seek treatment early, said Dr. Mitchell Berger, interim director of the Georgia Cancer Center for Excellence at Grady.
"A lot of our patients don't have access to health information," Berger said. "If they're working, they have jobs that don't allow them to take time off for a mammogram or colonoscopy. They may have cultural issues that keep them from seeking health care."
Dr. Otis Brawley, Berger's predecessor as head of the center, agrees.
"Insurance versus non-insurance is a great marker for people who are socially deprived or poor," said Brawley, now chief medical officer of the Cancer Society. "While giving people insurance would improve things, it will not improve everything."
Education and information can increase early diagnosis, even in a patient population like the Grady cancer center with only 10 percent private insurance coverage, said Brawley.
From 2001 until 2007, with funds from the state, Emory University and the Avon Foundation, Grady was able to establish a program of community education and mammography screening that shifted the pattern of diagnosis, Brawley said.
The percentage of women diagnosed with late-stage breast cancer was halved; the rate of early diagnosis was doubled.
The result, he said, was that more women had less extensive treatment and lived longer.
Dr. Bruce Feinberg, author of the "Cancer Answers" book series and CEO of Georgia Cancer Specialists, said he saw three late-stage cancer patients with no insurance in his private practice last week. One had colon cancer that had spread to her liver, one had a rare form of skin cancer that would require extensive surgery and chemotherapy, and one had breast cancer that had gone into her bones.
In all three cases, he said, early diagnosis through screening or a physical examination could have saved tens of thousands of dollars and possibly added years to their lives.