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Health Insurance and Breast-Conserving Surgery With Radiation Treatment

Askal Ayalew Ali, MA; Hong Xiao, PhD; and Gebre-Egziabher Kiros, PhD
Type of health insurance plays a significant role in the likelihood of receiving the recommended treatment among women diagnosed with early-stage breast cancer.

To examine the impact of health insurance type on treatment of early-stage breast cancer using breast-conserving surgery (BCS) with radiation therapy (RT) among women in Florida and identify factors that contribute to the variations in receiving the treatment in women with the same health insurance type.

Study Design and Methods

Breast cancer cases diagnosed during 1997 to 2002 were obtained from the Florida Cancer Data System. Women 40 years and older diagnosed with localized breast cancer were included. Demographic, insurance, and treatment information were extracted and linked with 2000 census data. χ² and multilevel logistic regression analyses were used.


A total of 33,706 women were diagnosed with localized breast cancer in Florida during 1997 to 2002. The average age of the women was 66 years, 58.62% had BCS while 38.61% had mastectomy, and only 2.77% had no surgical treatment. Type of health insurance plays a significant role in receiving BCS with RT. Furthermore, we found significant variations in the use of BCS with RT among women who have the same type health insurance by marital status, age, tumor size, year of diagnosis, level of education, and poverty level.


Although clinical practice guidelines recommend BCS with RT to treat women with localized breast cancer, significant differences in receiving the recommended treatment is found between and within types of health insurance. Identifying cultural barriers and educating the public about available treatment options are the major policy implications of this study. These observed differences require further study.

Am J Manag Care. 2014;20(6):502-516
Examined the impact of type of health insurance in receiving BCS with radiation and identified factors that contribute to such variations among women diagnosed with early-stage breast cancer who were covered with the same insurance.
  • Type of health insurance was significantly associated with the likelihood of receiving BCS with radiation.

  • Significant differences were found by race, marital status, age, and education among women who have the same health insurance. n Identify barriers and develop interventions to educate certain demographics to bridge the gap in treatment disparities.
Breast cancer occurs in both genders; however, it is the second leading cause of cancer death in women, behind only lung cancer.1 Florida ranks third in the United States for new breast cancer cases and for breast cancer deaths.1 There are variations in the incidence and mortality in breast cancer by race and ethnicity, and certain racial and ethnic groups are more vulnerable to breast cancer than others.2 For example, white women are more likely to be diagnosed with breast cancer, while black women are more likely to die from it.3 Differences in survival rates have been attributed to a variety of causes: late-stage diagnosis, type of treatment, characteristics of the tumor, and type of health insurance.3-7 Specifically, it has been reported that Medicaid-insured patients with breast cancer have the lowest 8-year survival rates.8

Since 1990, the death rates for breast cancer have been steadily declining due to earlier detection and improved treatment.1 Receiving timely treatment for newly diagnosed breast cancer is an important predictor of patient survival for localized breast cancer.9 Women treated for localized breast cancer are more likely to survive than women treated for late-stage cancer.10 Surgery (breast-conserving surgery [BCS], partial mastectomy, or full mastectomy), chemotherapy, radiation therapy (RT), and hormone therapy are some of the treatment options available for patients with breast cancer. Breast conservation therapy with radiation and mastectomy are equally effective for early-stage breast cancer and have similar survival rates.11-15 The National Institutes of Health Consensus Development Conference on Treatment of Early- Stage Breast Cancer16 recommends BCS with RT as the appropriate therapy for stage 1 and stage 2 breast cancer. BCS with RT is preferable to total mastectomy because it preserves the breast without shortening survival. The advantages of improved self-image and emotional well-being may make BCS the preferred treatment choice for women with stage 1 or stage 2 breast cancer.13

Decisions related to treatment options for early-stage breast cancer can be influenced by several intertwined factors that operate at various levels. Even though BCS/RT and mastectomy are equally recommended treatments, the mastectomy rate in the late 2000s has increased to a rate similar to that of the 1990s, after showing a substantial decline in the early/mid 2000s.17 In fact, excessive use of mastectomy has been well documented.18 The preference for mastectomy has been attributed particularly to misconceptions about BCS and physicians’ use of inappropriate selection criteria.19 Other studies have shown that choosing BCS is influenced by type of health insurance,8 marital status,20 and level of high school education attained.21,22 A recent study has documented that while BCS has become an increasingly popular choice, the use of RT after BCS has been decreasing.23

The literature on the effect of the type of health insurance a woman has on the use of RT after BCS presents an unclear picture. A study that used data from the Metropolitan Detroit Cancer Surveillance System (n = 5719) found that women insured with Medicaid were less likely to use BCS with RT than women who were not insured with Medicaid.8 Another study that used data obtained from 4 hospitals in the metropolitan New York area (n = 731) documented that Medicaid-insured and uninsured women were also less likely to use RT after BCS relative to privately insured or Medicare-insured women.24 Both studies used data collected between 1994 and 1997. Using data collected between 1997 and 2000 (n = 23,817) from the Florida Cancer Data System (FCDS), Voti and colleagues reported that while Medicareinsured women were more likely to use standard treatment (mastectomy or BCS with RT) for local breast cancer than privately insured women, the uninsured as well as Medicaid- insured were less likely to use standard treatment for local breast cancer than privately insured women.20

The aim of this study was to examine the impact of health insurance type on treatment of early-stage breast cancer using the recommended BCS with RT, and identify factors that contribute to women’s decision to choose such treatment. An additional aim of the study was to investigate racial/ethnic differences in the use of recommended treatment.

This study has 3 specific objectives: (1) to examine the impact of health insurance type and other socioeconomic and demographic factors on the use of BCS in combination with RT among women diagnosed with local breast cancer in Florida between 1997 and 2002 using a multilevel approach; (2) to investigate racial/ethnic differences in the use of recommended treatment and identify additional factors that contribute to the differences among women who were covered with the same type of health insurance; and (3) to analyze the trends in the use of recommended RT after BCS using a statewide cancer registry system.

There has been an unmet need for research on the relationship between race/ethnicity and the availability of advanced and shifting treatment choices and the role of health insurance type in eliminating health disparities. This study attempts to fill the gap in our knowledge about the impact of type of health insurance and other social and demographic factors on the use of RT after BCS and identify common and unique factors that contribute to disparities in the use of recommended treatment for breast cancer. The ongoing debate about health insurance and access to healthcare, in particular with the 2010 enactment of the Affordable Care Act (ACA), makes this study not only important, but timely.

In this paper, we used the Health Seeking Behavior Model (HSBM), the first conceptual behavioral model developed mainly to deal with public health problems,25 to examine factors associated with the likelihood of receiving BCS with radiation. The HSBM provides a useful theoretical framework and may help us better understand treatment choices women make after receiving a localized breast cancer diagnosis. It specifically models how patients use or do not use different kinds of health services. According to the model, factors related to use of healthcare services are characteristics of the patient (age, sex, marital status, ethnicity, education, and resources), service characteristics, and the characteristics as well as the patient’s perception of the disorder. The HSBM has been used to investigate the choices people make about whether or not to use various health services.26


Data Source

To examine the impact of health insurance coverage on receiving BCS with RT for localized breast cancer, we obtained data for the years 1997 to 2002 from the FCDS. This registry began collecting data in 1981 on the incidence of cancer. Hospitals, ambulatory diagnostic and treatment centers, clinical laboratories, and physicians’ offices are required by Florida law to electronically report most malignant cancers on a quarterly basis.

The database contains patient demographic information, characteristics of the tumor, insurance status and type, type of treatment received, as well as the provider’s identification information. To examine the impact of poverty and education, we linked FCDS data with the 2000 United States Census at the census tract level.

Study Population

Women 40 years and older who were diagnosed with localized breast cancer during the time period of 1997 to 2002 were included in the study. Only new cases of breast cancer were included in the study. Patients presenting with recurring breast cancer were excluded. Census data for the year 2000 was used because this year represents the midpoint of the study period. Cases with missing or unknown values for the study variables were excluded from the analysis. The linkage between the FCDS and census data was completed using state, county, and census tract codes. The data extraction and linkage process is summarized and shown in eAppendix A (available at

Study Variables

The outcome variable of interest was a dichotomous variable indicating the choice of treatment for localized breast cancer. Localized breast cancer is defined as cancer that originated in the breast and has not spread to the surrounding tissue or organs. The types of surgical treatment for localized breast cancer are BCS and mastectomy. BCS is defined as partial mastectomy with nipple resection, lumpectomy or excisional biopsy, reexcision of the biopsy site for gross or microscopic residual disease, and segmental mastectomy (including wedge resection, quadrantectomy, tylectomy). Mastectomy is defined as subcutaneous mastectomy, total (simple) mastectomy, modified radical mastectomy, radical mastectomy, and extended radical mastectomy. The FCDS also allows entries for no surgery, surgery, not otherwise specified, and unknown. Surgery, not otherwise specified, and unknown were not included in the analysis. The FCDS data include 9 categories of RT: no radiation; beam radiation; radioactive implant; radioisotopes; combinations of beam radiation with radioactive implants or radioisotopes (combination of 1 with 2 and/or 3); RT method or source not specified (NOS); patient or patient’s guardian refused; RT recommended, unknown if administered; and unknown if RT administered. The following categories were not included in this study: RT recommended, unknown if administered and unknown if RT administered.

The treatment guidelines for localized breast cancer from the NCCN12 recommends a lumpectomy followed by RT of varying intensities. FCDS includes both the date of surgery and the date radiation was administered, allowing the researcher to see if radiation treatment was administered after surgery.

The dependent variable is the use (code value 1) or nonuse (code value 0) of BCS with RT. The following individual- level explanatory variables were identified: patient’s type of health insurance, age, race, marital status, tumor size, and year of diagnosis. Insurance status was defined by the primary method of payment at the time of diagnosis, and it has 5 categories. Marital status represented the marital status of the women at the time of diagnosis. Age represented age at diagnosis. The census tract-level variables were represented as percent with a high school education and percent who were below the poverty level. Education was defined as a percentage of adults 25 years and older who have a high school diploma (from census tract). The poverty level was defined as the percentage of population with income in 1999 below the poverty level. A list of the independent variables used, definitions, and how they were measured or coded are presented in eAppendix B.

Statistical Analysis We applied a multilevel logistic regression analysis to examine how individual and census tract-level factors are associated with receiving recommended BCS with RT. We used a 2-level logistic regression to account for the clustering of women within census tracts with the assumption that they shared the same environment. The model we used can be summarized as follows: Let yij represent a binary treatment option of the ith woman diagnosed with localized breast cancer living in the jth census tract. The probability that this woman will

1n (Pij/1-Pij) = x t/ij β + uj        (1)

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