Department of Surgery, Washington University School of Medicine, St. Louis, Missouri.
Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri.
Cancer. 2021 Mar 15;127(6):931-937. doi: 10.1002/cncr.33330. Epub 2020 Nov 17.
The cancer stage at diagnosis, treatment delays, and breast cancer mortality vary with insurance status.
Using the Missouri Cancer Registry, this analysis included 31,485 women diagnosed with invasive breast cancer from January 1, 2007, to December 31, 2015. Odds ratios (ORs) of a late-stage (stage III or IV) diagnosis and a treatment delay (>60 days after the diagnosis) were calculated with logistic regression. The hazard ratio (HR) of breast cancer mortality was calculated with Cox proportional hazards regression. Mediation analysis was used to quantify the individual contributions of each covariate to mortality.
The OR of a late-stage diagnosis was higher for patients with Medicaid (OR, 1.72; 95% confidence interval [CI], 1.56-1.91) or no insurance (OR, 2.30; 95% CI, 1.91-2.78) in comparison with privately insured patients. Medicare (OR, 1.21; 95% CI, 1.10-1.37), Medicaid (OR, 1.60; 95% CI, 1.37-1.85), and uninsured patients (OR, 1.58; 95% CI, 1.18-2.12) had higher odds of a treatment delay. The HR of breast cancer-specific mortality was significantly increased in the groups with public insurance or no insurance and decreased after sequential adjustments for sociodemographic factors (HR, 2.39; 95% CI, 1.96-2.91), tumor characteristics (HR, 1.28; 95% CI, 1.05-1.56), and treatment (HR, 1.23; 95% CI, 1.01-1.50). Late-stage diagnoses accounted for 72.5% of breast cancer mortality in the uninsured.
Compared with the privately insured, women with public or no insurance had a higher risk for advanced breast cancer, a >60-day treatment delay, and death from breast cancer. Particularly for the uninsured, Medicaid expansion and increased funding for education and screening programs could decrease breast cancer disparities.
诊断时的癌症分期、治疗延迟和乳腺癌死亡率因保险状况而异。
本研究利用密苏里州癌症登记处的数据，分析了 2007 年 1 月 1 日至 2015 年 12 月 31 日期间诊断为浸润性乳腺癌的 31485 名女性。采用逻辑回归计算晚期（III 期或 IV 期）诊断和治疗延迟（诊断后超过 60 天）的比值比（OR）。采用 Cox 比例风险回归计算乳腺癌死亡率的风险比（HR）。采用中介分析量化每个协变量对死亡率的个体贡献。
与私人保险患者相比，医疗补助（OR，1.72；95%置信区间[CI]，1.56-1.91）或无保险（OR，2.30；95%CI，1.91-2.78）的患者晚期诊断的 OR 更高。医疗保险（OR，1.21；95%CI，1.10-1.37）、医疗补助（OR，1.60；95%CI，1.37-1.85）和无保险患者（OR，1.58；95%CI，1.18-2.12）治疗延迟的可能性更高。在考虑社会人口统计学因素（HR，2.39；95%CI，1.96-2.91）、肿瘤特征（HR，1.28；95%CI，1.05-1.56）和治疗（HR，1.23；95%CI，1.01-1.50）后，乳腺癌特异性死亡率的 HR 显著升高。无保险组的乳腺癌死亡率增加，而有公共保险或无保险的女性乳腺癌晚期诊断、治疗延迟超过 60 天的风险更高。在无保险人群中，晚期诊断占乳腺癌死亡的 72.5%。
与私人保险相比，公共保险或无保险的女性患有晚期乳腺癌、治疗延迟超过 60 天以及死于乳腺癌的风险更高。特别是对于没有保险的人群，扩大医疗补助和增加教育和筛查计划的资金可以减少乳腺癌的差异。
