J. D. Borgella1, F. Espinoza-Mercado1, T. Imai1, R. Alban1, H. Soukiasian1 1Cedars-Sinai Medical Center,Department Of Thoracic Surgery,Los Angeles, CALIFORNIA, USA
Introduction: Previous studies have shown disparities in esophageal cancer-related mortality rates among different races and those with lower socioeconomic status. Very little data exists on the role of insurance in outcomes of esophageal cancer, particularly for surgical candidates. We sought to identify the differences in the uninsured vs. insured patient population including the time interval from diagnosis to surgery (DTS) and survival.
Methods: The National Cancer Data Base (NCDB) was queried for patients diagnosed with pathologic Stage 0-IV esophageal cancer from 2004-2014. Insurance status was stratified into two groups: Insured vs. Uninsured. Demographics and clinical characteristics were analyzed between groups. Time interval for DTS was estimated for both groups; overall survival was calculated using the Kaplan-Meier curves and the log-rank test was used to compare survival distributions.
Results: From 2004-2014 there were 125,493 patients diagnosed with esophageal cancer. Of which 4,495 (3.6%) were uninsured. Of these, 787 (17.5%) received a surgical procedure compared to 31.5% of the 120,998 insured patients. 42.2% of uninsured patients were less than 55 years old vs. 14.5% of insured patients. Blacks and Hispanics represented 23.2% and 8.8% of uninsured patients vs. 9.2% and 3% of insured patients. 31.9% of uninsured patients made less than $38K a year vs. 18% of insured patients. Interestingly uninsured patients had a lower Charlson-Deyo score compared to insured patients (CD = 0, 79.7% vs. 72.5%, respectively p< 0.001). Of all patients who received a definitive surgical procedure, uninsured patients waited longer for surgery (105 days vs. 94 days, p<0.01). The greatest differences were noted in Stage I disease, where the difference in DTS was 87 days, interquartile range (IQR) 64-119 days compared to insured patients (68 days, IQR 27-98 days, p=0.034). Uninsured patients had a statistically significant worse overall survival at every stage, particularly in stage I which had a survival of 26.3 months for the uninsured compared to 46.9 months in the insured (p< 0.01). There was no statistically significant difference in the two groups from time of diagnosis to chemotherapy or radiation therapy.
Conclusion: Uninsured patients with stage 1 esophageal cancer receive definitive surgical treatment later than their insured counterparts and have worse survival. This disparity is also noted on other stages. Understanding the role of insurance in access to care for this cohort warrants further analysis.
