The Impact of Insurance Status on Outcomes for Bladder Cancer
Alexander P. Cole, MD1, Sean Fletcher, BS2, Chang Lu, MS3, Marieke Krimphove, MD4, Stuart Lipsitz, ScD1, Quoc-Dien Trinh, MD1
1Brigham & Women's Hospital, Harvard Medical School, Boston, MA, 2Harvard Medical School, Boston, MA, 3Harvard School of Public Health, Boston, MA, 4University of Frankfurt, Frankfurt, Germany
Background: Health disparities in the United States are closely linked to patients’ ability to afford care. Bladder cancer is known to impart a substantial financial burden upon diagnosed individuals. We sought to determine the association between insurance status and clinical outcomes in bladder cancer. Methods: We used the Surveillance, Epidemiology, and End Results (SEER) database and the National Cancer Database (NCDB) to identify men and women aged <65 years who were diagnosed with bladder cancer from 2007 to 2014. With SEER, we evaluated the association between insurance status (private insurance, Medicaid insurance, and lack of insurance) and diagnosis with muscle-invasive bladder cancer as well as bladder cancer-specific survival. NCDB was used to identify those with localized muscle-invasive bladder cancer and evaluate the association between insurance status and receipt of neoadjuvant chemotherapy (among those who underwent radical cystectomy) as well as post-diagnosis delay of any treatment (surgery, radiation, or chemotherapy) > 3 months. Analyses were controlled for age, sex, race, year of diagnosis, income, education, geographical region, clinical TNM stage, and histologic type. Results: There were 29,525 individuals in the SEER cohort and 6,069 in the NCDB cohort. Multivariable analyses (with private insurance holders as the reference group) demonstrated that uninsured individuals were nearly twice as likely to receive a diagnosis of muscle-invasive bladder cancer (OR: 1.90; 95% CI: 1.70 - 2.12). Medicaid-insured individuals had similarly increased odds of receiving this diagnosis (OR: 2.03; 95% CI: 1.87 - 2.20). Uninsured patients were also more likely to die of bladder cancer (adjusted hazard ratio [AHR]: 1.49; 95% CI: 1.31 - 1.71), as were those with Medicaid coverage (AHR: 1.61; 95% CI: 1.46 - 1.79). Uninsured patients were less likely to receive neoadjuvant chemotherapy (OR: 0.76; 95% CI: 0.59 - 0.97) and more likely to experience a delay in treatment (OR: 1.50; 95% CI: 1.22 - 1.83). These outcomes were similar for Medicaid-insured patients. Conclusions: Individuals lacking insurance and those with Medicaid coverage are more likely to be diagnosed with muscle-invasive bladder cancer as well as die from the disease; they are also less likely to receive guideline-directed care. Expanding high-quality insurance coverage may help to reduce the burden of this disease.
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