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Health Insurance and Breast-Conserving Surgery With Radiation Treatment
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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.
Consistent with the results displayed in the Figure, after controlling for the effects of marital status, age, size of tumor, year of diagnosis, poverty and education, we found that in the group of women insured by Medicaid, non-Hispanic black women were more likely to have the recommended treatment than were non-Hispanic white women (OR = 2.08; 95% CI, 1.13-3.83). No significant difference was found by race/ethnicity in the likelihood of receiving the recommended treatment among women insured with the other 4 health insurance types. It is important to note that, although statistically non-significant, among the uninsured women, non-Hispanic black women (27%) and Hispanic women (25%) were less likely to receive RT after BCS relative to non-Hispanic white women. Single women were 19% (OR = 0.81; 95% CI, 0.69-0.94) and 24% (0.76; 95% CI, 0.64-0.90) less likely to receive BCS with RT than married women in the privately insured and Medicare populations, respectively. Age at diagnosis as well as age-squared were also significant predictors in the receipt of the recommended treatment, except in the uninsured group, suggesting that the nonlinear effect of age still holds in the insurance-specific models. As expected, tumor size and the likelihood of receiving BCS with RT were inversely related. Year of diagnosis was not significantly related to the use of the recommended treatment among Medicaid- insured women. But significant relationships between year of diagnosis and the use of recommended treatment were found among women in the remaining health insurance types showing that women who were diagnosed with early stage breast cancer in 1997 were significantly less likely to receive the recommended treatment than were women diagnosed in 2002.

Concerning the effects of census tract-level variables, contrary to our expectation, an increase in the poverty levels for the census tracts in which the women resided were positively associated with the likelihood of getting the recommended treatment in the Medicaid-insured women. The effect of education in receiving the recommended treatment was consistent and significant across all health insurance types, indicating that women who lived in neighborhoods that had higher percentages of educated population had an increased likelihood of receiving the recommended treatment. The census tractlevel random intercept estimates were significant in the private, Medicare, and “other” health insurance type models. Again, this indicated the appropriateness of our modeling approach since failing to account for the correlation among women who resided in a given census tract may have led to biased estimates and consequently to misleading conclusions.

DISCUSSION

Since the early 1990s, BCS in combination with RT has become a standard—a recommended treatment for eligible women with early-stage breast cancer—and has replaced mastectomy as the leading treatment because it provides similar outcomes to mastectomy while preserving the breast.27 This study examined the impact of health insurance and other factors on the receipt of the recommended treatment over a 6-year period in the state of Florida. A distinguishing feature of our study was the simultaneous consideration of patient characteristics and community factors as predictors in the use of the recommended treatment for early-stage breast cancer using a multilevel modeling approach and an investigation of racial/ ethnic disparities stratified by health insurance type. Data obtained from the FCDS for the period of 1997 to 2002 were merged with the 2000 census data. Descriptive statistics, χ² analysis, and multilevel logistic regression were used for data analysis. Our investigation on the impact of health insurance type on the receipt of recommended treatment accounted for the effects of other factors including race/ethnicity, age, marital status, size of tumor, year of diagnosis, poverty, and education, as well as unobserved factors at the census tract level that may contribute to receiving the treatment.

Overall, the average use of BCS and mastectomy between 1997 and 2002 were 58.62% and 38.61%, respectively. On the use of RT following BCS, we found that only 47.45% of women with early-stage breast cancer reported RT. According to the American College of Radiology,27 close to 80% of patients with early-stage breast cancer are suitable candidates for breast-conserving therapy. However, it is reported that in the United States, only between 38% and 65% of patients choose this treatment. In addition to indicating an underuse of the recommended therapy in our study population, the lower rate may also be an indicator of a problem of underreporting in RT. Yet, the reported low rate of RT use following BCS is consistent with 2 previous studies that used FCDS.20,28 Using the FCDS, Voti and colleagues21 documented that 48.5% of women received RT after BCS between 1997 and 2000. Another study29 that used year 2001 data from the FCDS documented a rate of 43% for 2001, which is in agreement with the rate reported for 2001 in Table 2 (43.19%). A study by McGuire and colleagues30 found that mastectomy and BCS combined with RT rates for patients treated for invasive and in situ breast cancer at the Moffitt Cancer Center between 1994 and 2007 were 63.7% and 36.3%, respectively, although the authors acknowledge their study population was a more homogenous population with respect to socioeconomic status. Although the data they used came from patients treated in 1 center instead of from a state-wide cancer registry system, it still highlights the possibility of a serious problem of underreporting of RT in the FCDS.

Health Insurance Type and BCS With RT

Our analysis confirmed significant differences among women diagnosed with early-stage breast cancer in the use of recommended treatment by health insurance type. Differences in treatment options by health insurance have been reported in past studies.6,20,31,32 Furthermore, the finding that women insured by Medicare were 10% more likely (OR = 1.10; 95% CI, 1.02-1.18) to receive BCS with radiation than were women with private health insurance is in agreement with 2 previous studies.20,32 Similarly, women insured by “other” programs were also more likely to receive BCS with RT than women with private health insurance. Similar to Voti and colleagues,20 our findings did show a trend that women enrolled under Medicaid were 20% (OR = 0.80, 95% CI, 0.64-1.01) less likely to receive the recommended treatment compared with privately insured women, although our findings were not statistically significant. One plausible explanation for the differences in receiving the recommended treatment between private insurance, Medicare, and “other” insurance could be related to reimbursement plans and treatment modalities available during the specific time the patient was treated, or to the amount of out-of-pocket co-payment, as reported in other studies.20 The variations in type of treatment may also partly depend on possible differences in recommendations of the physician-based reimbursement schedules and incentives of health insurance plans, patient characteristics, and factors like comorbidity.33

In contrast to previous studies,6,19-21 we found no difference in the receipt of recommended treatment by race/ ethnicity in the nonstratified analysis. This could be attributed in part to the type of covariates we included as a control, as well as the multilevel approach we used. The relationship between age and the likelihood of receiving the recommended treatment was significant and nonlinear. The odds of a woman to undergo BCS with RT increased with age and then decreased for older women (after age 70 years). This finding was also similar to other studies.19,32,35 As noted by Silliman and colleagues35 and the American College of Radiology,28 for women older than 70 years, omission of RT after BCS is a preferable option especially if the patient has comorbid conditions. Year of diagnosis also played a role in the likelihood of receiving BCS with RT, which was supported by the literature.34 In contrast to 1 previous study that found a decrease in the use of the recommended treatment over time,23 this study found an increase in the use of the recommended treatment over time. Our findings also showed that being unmarried was a risk factor for not receiving the recommended treatment. This finding was also in agreement with earlier, similar studies20,35 and may be attributed to married women having more information and access to social support and social networks that encourage recommended treatment.

Before the analysis was stratified by health insurance type, of the 2 census tract-level variables included in our model, poverty was not associated with the receipt of recommended treatment. But living in a neighborhood with a higher education level was positively associated with an increased likelihood of receiving the recommended treatment. The environment in which patients reside exerts an important influence on the receipt of recommended treatment since neighborhoods with more educated people are capable of creating a higher percentage of patients who are informed about their health. Moreover, patients who reside in neighborhoods where there is higher proportion of educated people are also likely to be educated themselves and therefore have more knowledge and awareness about their health, including cancer diagnostics and treatment. Also, they may have better access to timely and accurate information from community organizations, health clubs, or online sources regarding the importance of cancer screening and the availability of certain treatment options. A positive association of education and the receipt of recommended treatment was also supported by past research.21,22,34,36

Stratified Analysis of BCS With RT

In further analysis, this study sought to find the factors that were associated with variations in the receipt of BCS with RT among women who have had the same type of health insurance by estimating insurance-specific multilevel models. There were common as well as unique insurance-specific predictors of the use of recommended treatment. Education and tumor size were the only common significant factors that predicted the receipt of recommended treatment across all 5 types of health insurance coverage. Tumor size of 2 cm or larger and unknown size were significantly associated with receipt of BCS with RT less often compared with tumor size of less than 2 cm in the whole (nonstratified) analysis as well as across all insurance types. This is consistent with previous studies. 27,29,35,37 Age was also an important predictor in all types of health insurance except the uninsured. Year of diagnosis was a significant predictor in all but Medicaid-insured women. Results show an increase in the use of the recommended treatment in 2002 compared with 1997 among women insured by private, Medicare, or “other” insurance plans or who were not insured, while a modest trend was observed in the use of the recommended treatment in the period of 1997 to 2002 among Medicaid recipients. Single women were 19% (OR = 0.81; 95% CI, 0.69-0.94) and 24% (OR = 0.76; 95% CI, 0.64-0.90) less likely to receive BCS with RT than married women in the privately insured and Medicare populations, respectively.

 
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