Churilla Thomas M, Egleston Brian, Bleicher Richard, Dong Yanqun, Meyer Joshua, Anderson Penny
Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania.
Department of Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center, Philadelphia, Pennsylvania.
Breast J. 2017 Mar;23(2):169-176. doi: 10.1111/tbj.12705. Epub 2016 Oct 31.
Although standard practice guidelines for breast cancer are clear, the interplay between insurance and practice patterns for the US is poorly defined. This study was performed to test for associations between patient insurance status and presentation of breast cancer as well as local therapy patterns in the US, via a large national dataset. We queried the NCI Surveillance, Epidemiology, and End Results data base for breast cancer cases diagnosed from 2007 to 2011 in women aged 18-64 with nonmetastatic ductal/lobular cancers, treated surgically. We tested for associations between insurance status (insured/Medicaid/uninsured) and choice of surgical procedure (mastectomy/breast conserving surgery [BCS]), omission of radiotherapy (RT) following BCS, and administration of post-mastectomy radiation (PMRT). There were 129,565 patients with localized breast cancer analyzed. The health insurance classification included insured (84.5%), Medicaid (11.5%), uninsured (2.1%) and unknown (1.9%). Medicaid or uninsured status was associated with large, node positive tumors, black race, and low income. The BCS rate varied by insurance status: insured (52.2%), uninsured (47.7%), and Medicaid (45.2%), p < 0.001. In multivariable analysis, Medicaid insurance remained significantly associated with receipt of mastectomy (OR [95% CI] = 1.07 [1.03-1.11]), while RT was more frequently omitted after BCS in both Medicaid (OR [95% CI] = 1.14 [1.07-1.21]) and uninsured (OR [95% CI] = 1.29 [1.14-1.47]) patients. Insurance status was associated with significant variations in breast cancer care in the US. Although patient choice cannot be determined from this dataset, departure from standard of care is associated with specific types of insurance coverage. Further investigation into the reasons for these departures is strongly suggested.
尽管乳腺癌的标准治疗指南很明确，但美国保险与治疗模式之间的相互作用却界定不清。本研究旨在通过一个大型全国性数据集，检验美国患者保险状况与乳腺癌表现以及局部治疗模式之间的关联。我们查询了美国国立癌症研究所监测、流行病学和最终结果数据库，以获取2007年至2011年期间诊断为非转移性导管/小叶癌、接受手术治疗的18至64岁女性乳腺癌病例。我们检验了保险状况（参保/医疗补助/未参保）与手术方式选择（乳房切除术/保乳手术[BCS]）、BCS后放疗（RT）的省略以及乳房切除术后放疗（PMRT）的实施之间的关联。共分析了129,565例局部乳腺癌患者。健康保险分类包括参保（84.5%）、医疗补助（11.5%）、未参保（2.1%）和不明（1.9%）。医疗补助或未参保状况与肿瘤大、有淋巴结转移、黑人种族和低收入相关。BCS率因保险状况而异：参保者为52.2%，未参保者为47.7%，医疗补助者为45.2%，p<0.001。在多变量分析中，医疗补助保险仍与接受乳房切除术显著相关（比值比[95%置信区间]=1.07[1.03 - 1.11]），而在医疗补助患者（比值比[95%置信区间]=1.14[1.07 - 1.21]）和未参保患者（比值比[95%置信区间]=1.29[1.14 - 1.47]）中，BCS后更常省略RT。在美国，保险状况与乳腺癌治疗的显著差异相关。尽管无法从该数据集中确定患者的选择，但偏离治疗标准与特定类型的保险覆盖相关。强烈建议进一步调查这些偏离的原因。
