S. Obeng-Gyasi1, L. Timsina1, K. D. Miller3, G. L. Dunnington1, K. K. Ludwig1, D. A. Haggstrom2 1Indiana University School Of Medicine,Department of Surgery,Indianapolis, IN, USA 2Indiana University School Of Medicine,Department Of Medicine,Indianapolis, IN, USA 3Indiana University School Of Medicine,Division Of Hematology And Oncology,Indianapolis, IN, USA
Introduction: Uninsured and Medicaid insured breast cancer patients have a worse overall survival compared to their privately insured counterparts. Federally funded programs such as the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) seek to mitigate this disparity by providing uninsured and underinsured women access to preventive care such as screening mammograms. There have been no studies examining whether Indiana’s Breast and Cervical Cancer Program (BCCP) improves treatment outcomes and mortality among breast cancer patients. To this end, the objective of this study is to identify the differences in overall treatment (surgery, chemotherapy, radiation therapy and hormone therapy) and mortality among uninsured patients diagnosed through Indiana’s BCCP compared to privately insured individuals and government insured individuals (Medicaid or Medicare).
Methods: Study data was obtained using the Indiana state cancer registry and Indiana BCCP records. Women ages 50-64 with an index diagnosis date of stage 0-III breast cancer from 01/01/2006-12/31/2013 were included in the study. The data was divided into five insurance groups-uninsured (BCCP only group), privately insured, Medicaid, Medicare and other. Bivariate intergroup analysis was conducted using chi squared, student T tests, and ANOVA followed by Tukey’s pairwise comparison of the means as appropriate. Kaplan Meier estimates between the five insurance types were compared using the log rank test.
Results:1477 individuals fulfilled the inclusion criteria. Approximately 24% of the study population was uninsured, 53% private insurance, 11% Medicaid, 11% Medicare and 1% another payment plan. The groups differed significantly by age, educational attainment, metropolitan status, neighborhood poverty index, clinical stage, surgery type (mastectomy vs lumpectomy), chemotherapy and endocrine therapy. BCCP patients (BCCP 27% vs private 11%) were more likely to present with stage 3 breast cancer (p=0.04). Intergroup bivariate analysis by stage revealed differences in the utilization of chemotherapy, radiation therapy, surgery type and lymph node surgery based on insurance type. Clinically stage 3 BCCP patients were more likely to undergo a lumpectomy (BCCP 31% vs private 14%, p=0.009) and ALND (BCCP 98% vs private 43%, p=0.001). Kaplan Meier estimates showed uninsured individuals had the highest mortality (p=0.0015). The divergence in mortality between the uninsured BCCP subjects and the remaining insurance subtypes was evident at 3 years from diagnosis.
Conclusion: Breast cancer patients diagnosed through Indiana BCCP are more likely to have worse overall mortality. Possible explanations for this disparity include delayed diagnosis or differences in treatment. Future studies should explore how increased access to screening mammography provided by the BCCP program can be better leveraged to realize the goal of reduced disparities in treatment and mortality.