Insurance Status Helps Explain Racial Disparities in Cancer Diagnosis
Posted on by Dr. Francis Collins
Women have the best odds of surviving breast cancer if their disease is caught at an early stage, when treatments are most likely to succeed. Major strides have been made in the early detection of breast cancer in recent years. But not all populations have benefited equally, with racial and ethnic minorities still more likely to be diagnosed with later-stage breast cancer than non-Hispanic whites. Given that recent observance of Martin Luther King Day, I thought that it would be particularly appropriate to address a leading example of health disparities.
A new NIH-funded study of more than 175,000 U.S. women diagnosed with breast cancer from 2010-2016 has found that nearly half of the troubling disparity in breast cancer detection can be traced to lack of adequate health insurance. The findings suggest that improving insurance coverage may help to increase early detection and thereby reduce the disproportionate number of breast cancer deaths among minority women.
Naomi Ko, Boston University School of Medicine, has had a long interest in understanding the cancer disparities she witnesses first-hand in her work as a medical oncologist. For the study published in JAMA Oncology, she teamed up with epidemiologist Gregory Calip, University of Illinois Cancer Center, Chicago [1]. Their goal was to get beyond documenting disparities in breast cancer and take advantage of available data to begin to get at why such disparities exist and what to do about them.
Disparities in breast cancer outcomes surely stem from a complicated mix of factors, including socioeconomic factors, culture, diet, stress, environment, and biology. Ko and Calip focused their attention on insurance, thinking of it as a factor that society can collectively modify.
Many earlier studies had shown a link between insurance and cancer outcomes [2]. It also stood to reason that broad differences among racial and ethnic minorities in their access to adequate insurance might drive some of the observed cancer disparities. But, Ko and Calip asked, just how big a factor was it?
To find out, they looked to the NIH’s Surveillance Epidemiology, and End Results (SEER) Program, run by the National Cancer Institute. The SEER Program is an authoritative source of information on cancer incidence and survival in the United States.
The researchers focused their attention on 177,075 women of various races and ethnicities, ages 40 to 64. All had been diagnosed with invasive stage I to III breast cancer between 2010 and 2016.
The researchers found that a higher proportion of women receiving Medicaid or who were uninsured received a diagnosis of advanced stage III breast cancer compared with women with health insurance. Black, American Indian, Alaskan Native, and Hispanic women also had higher odds of receiving a late-stage diagnosis.
Overall, their sophisticated statistical analyses traced up to 47 percent of the racial/ethnic differences in the risk of locally advanced disease to differences in health insurance. Such late-stage diagnoses and the more extensive treatment regimens that go with them are clearly devastating for women with breast cancer and their families. But, the researchers note, they’re also costly for society, due to lost productivity and escalating treatment costs by stage of breast cancer.
These researchers surely aren’t alone in recognizing the benefit of early detection. Last week, an independent panel convened by NIH called for enhanced research to assess and explore how to reduce health disparities that lead to unequal access to health care and clinical services that help prevent disease.
References:
[1] Association of Insurance Status and Racial Disparities With the Detection of Early-Stage Breast Cancer. Ko NY, Hong S, Winn RA, Calip GS. JAMA Oncol. 2020 Jan 9.
[2] The relation between health insurance coverage and clinical outcomes among women with breast cancer. Ayanian JZ, Kohler BA, Abe T, Epstein AM. N Engl J Med. 1993 Jul 29;329(5):326-31.
[3] Cancer Stat Facts: Female Breast Cancer. National Cancer Institute Surveillance, Epidemiology, and End Results Program.
Links:
Cancer Disparities (National Cancer Institute/NIH)
Breast Cancer (National Cancer Institute/NIH)
Naomi Ko (Boston University)
Gregory Calip (University of Illinois Cancer Center, Chicago)
NIH Support: National Center for Advancing Translational Sciences; National Cancer Institute; National Institute on Minority Health and Health Disparities
the info in this article is not enough to draw the conclusion that it is a lack of insurance. We spend millions to Planned Parenthood who say they give free mammograms and women’s services. We have many non profits such as the Susan Komen Foundation that give millions of dollars in grants to medical facilities to give free mammo to low income women or those without insurance. I think the reason these women lack the care is that they themselves are not taking care of themselves and availing themselves of these options for healthcare. As well. MedicaId will cover these as well.
People on Medicaid generally have lower educational and economic status than the general population. In addition, some are immigrants with language and cultural barriers. The services mentioned are offered by Planned Parenthood and Susan Komen Foundation but there are barriers to people accessing them. For example, most people from a religious community would never go to Planned Parenthood for care because they associate it with the need for an abortion. Therefore, they would never know of all the other services offered by Planned Parenthood. Moreover, abortion is a very private matter, if they have gone to Planned Parenthood, they would never share the information. Health literacy is another factor that impacts patient’s ability to access preventive care. If the educational level is low, then, so is the health literacy level. As an immigrant and Registered Nurse working with underserved populations, I have witnessed the results of cultural and educational barriers on the health of my community. I do agree that the type of insurance you have does have an impact on care received.
A fascinating thought-provoking expert opinion by Dr. Collins!
I strongly believe that there is an urgent global need for strategic allocation of financial grants/federal-fund support for successfully diminishing the increasing trends of morbidity/mortality of cancers among ethnically distinct populations of varying socioeconomic strata, including lack of healthcare insurance coverage; in this context, emerging and established policy-makers, public health experts and translational health/medicine researchers/clinicians, should collaboratively develop cost-effective target-driven public health research models for cancer-diagnosis-prevention-surveillance with large multicentric cohorts of asymptomatic/borderline/symptomatic cancer subsets. In fact, my proven expertise in biomedical research and translational/public health as evident in my peer-reviewed publications amalgamating my medical research experiences and patients-interactions both in USA and my homecountry India have provided me considerable experience for advancing cancer-epidemiology-health disparities research for eventually meaningfully contributing to the cancer-patients’ and their immediate family, the satisfaction and motivation for confidently coping with cancer (early vs advanced cancer-stages of breast, HPV-Cervical, prostate, colorectal cancers, etc.)
Cancer surveillance, telemontoring with virtual clinics and care-givers-counselling with cancer awareness talks would further aid in cost-effective management of cancer worldwide with future design of predictive/prognostic biomarkers!
Effective January 1, 2020, the State of Connecticut has a new law mandating insurance coverage for Breast Ultrasound and MRI for women with heterogeneously dense breast tissue, with no cost-sharing and no deductible.Women with dense breast tissue (detected only on a screening mammogram) most often require follow-up testing, such as a breast ultrasound or an MRI, to rule out any small, early-stage, often non-palpable lesions missed on a screening mammogram. Five states have similar insurance mandates. This must become a Federal insurance mandate. Kudos to the authors of this study.
I have dense breast and they couldn’t find my cancer after ultra sound had to have MRI.It went on for two years even though my nipple was inward and breast was dimpled. When they did find it the tumor was 7.5 cc.and now I am stage 3 cancer.
This is really appreciated that you have presented these data … It will be very helpful to understand about insurance status helps explain racial disparities in cancer diagnosis Great post to share, thanks for publishing this here!!