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The American Journal of Managed Care June 2014
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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
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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.
The program was designed to identify cases not seen in any hospital or other facility, such as a radiation center owned by a hospital, and provides a reporting mechanism for centers to report to FCDS. It is also possible that some of the patients seen in free-standing centers for an initial course of therapy may have been reported by a hospital or another reporting facility without mention of the RT. In addition, there is a possibility that some women may have obtained treatment in other states and their information is not reported in the FCDS. However, the problem of underreporting in the FCDS is likely to affect all cases randomly and there is no reason to believe that it affects a certain group with respect to health insurance in a systematic way. In addition, the FCDS is a nationally recognized cancer registry system that is regularly enhanced. It is unlikely that this limitation will seriously affect the findings and conclusions of the study.

Second, our analysis does not cover the period after 2002 because the data was not available to us. With the rapid advancement of medical technology and new innovations, it is reasonable to assume that patterns of earlystage breast cancer treatment may have changed since then. Third, some key variables were not available in the data. For example, census tract-level high school completion rate was used as a proxy for education. Data availability hampers the inclusion of other variables that are desirable, such as comorbidity that interferes with cancer treatment and distance to a radiation treatment center. More importantly, this study was unable to capture the influence of patient’s breast size, patient’s preference, physician- patient interactions, family support, patient fear of genetic or recurrence risk, and other psychological factors that contribute to treatment choice. Fourth, type of facility and quality of care where treatment was received were not included in this study due to lack of data availability.

Another limitation was that the categories of health insurance type used were general. For instance, our study did not distinguish between normal Medicare and fee-forservice Medicare.

Policy Implications

Despite these limitations, this study was able to document the influence of health insurance and other variables on decisions related to receiving BCS with RT using a large data set from a statewide population-based cancer registry system. More importantly, we found common and unique factors that influence women’s decisions on receiving BCS with RT among women who had the same health insurance.

Our findings reveal that the choice of receiving BCS with RT varied not only between women with different health insurance types but also among women with the same health insurance. Overall, being unmarried (that is, single, divorced, or widowed) was a risk factor for not receiving the recommended treatment. This finding was also true among women insured either by Medicare or private insurance. Smaller tumor size and higher levels of education, measured by the percentage of the population with at least a high school education at census tract level, were the only common predictors that were associated with receiving the recommended treatment in all of our models, regardless of type of health insurance.

Hence, some of the policy implications of the study include: (1) uninsured women were less likely to use the recommended treatment, so increasing access to healthcare for women would prove especially beneficial; (2) initiating and implementing policy programs that aim to improve the education level of the general population is warranted, as having a higher percentage of high school educated individuals at the census tract level has a strong positive effect on people's willingness to use healthcare, regardless of type of health insurance; (3) increase awareness to minimize fear and misperceptions about radiation recurrence among women and educate patients about the importance of being compliant with the whole radiation treatment schedule; (4) develop public health programs that reach out to unmarried women by disseminating timely and accurate information about the benefits of treatment options.


The findings of this study provide better understanding regarding the type of surgical treatments provided to women diagnosed with early-stage breast cancer from 1997 to 2002, and the impact of type of health insurance in the receipt of recommended treatment in Florida. We found that access to healthcare has a substantial impact in the likelihood of receiving the recommended treatment among women diagnosed with localized breast cancer. Specifically, there was significant variation in the use of RT after BCS by type of health insurance. In addition, marital status, age, tumor size, year of diagnosis, and education level were significant predictors. Race/ethnicity was not significantly related to the use of RT after BCS. However, non-Hispanic black women were significantly associated with higher likelihood of receiving RT after BCS among Medicaid-insured than were non-Hispanic white women. Poverty was also significantly associated with higher likelihood of receiving radiation after BCS only among Medicaid-insured women. BCS with radiation is the recommended treatment for women with localized breast cancer with its usage having increased over time. The results must be interpreted with caution with the limitations of the study in mind. Our study calls for more inquiry into why non-Hispanic black women insured by Medicaid are more likely to use BCS with RT than non-Hispanic white women, and why single women with private insurance are less likely to use BCS with RT than married women. These observed differences require further study.

Author Affiliations: College of Pharmacy and Pharmaceutical Sciences, Division of Economic, Social, and Administrative Pharmacy, Florida Agricultural and Mechanical University, Tallahassee, FL (AA, HX); Institute of Public Health, College of Pharmacy and Pharmaceutical Sciences, Florida Agricultural and Mechanical University, Tallahassee, FL (G-EK)

Source of Funding: None reported.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (AAA, HX, G-EK); acquisition of data (AAA, HX); analysis and interpretation of data (AAA, G-EK); drafting of the manuscript (AAA, G-EK); critical revision of the manuscript for important intellectual content (AAA, HX); statistical analysis (AAA, G-EK); supervision (HX).

Address correspondence to: Gebre-Egziabher Kiros, PhD, Institute of Public Health, College of Pharmacy and Pharmaceutical Sciences, Florida Agricultural and Mechanical University, FSH Science Research Center, Rm #209-B, Tallahassee, Florida 32307. E-mail: ge.kiros@famu .edu.
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