The disparities of cancer survival among patients under health insirance.

The cancer stage at diagnosis, treatment delays, and breast cancer mortality vary with insurance status.

Previous studies using data from the early 2000s demonstrated that patients who were uninsured were more likely to present with late‐stage disease and had worse short‐term survival after cancer diagnosis in the United States. In this report, the authors provide comprehensive data on the associations of health insurance coverage type with stage at diagnosis and long‐term survival in individuals aged 18–64 years who were diagnosed between 2010 and 2013 with 19 common cancers from the National Cancer Database, with survival follow‐up through December 31, 2019. Compared with privately insured patients, Medicaid‐insured and uninsured patients were significantly more likely to be diagnosed with late‐stage (III/IV) cancer for all stageable cancers combined and separately. For all stageable cancers combined and for six cancer sites—prostate, colorectal, non‐Hodgkin lymphoma, oral cavity, liver, and esophagus—uninsured patients with Stage I disease had worse survival than privately insured patients with Stage II disease. Patients without private insurance coverage had worse short‐term and long‐term survival at each stage for all cancers combined; patients who were uninsured had worse stage‐specific survival for 12 of 17 stageable cancers and had worse survival for leukemia and brain tumors. Expanding access to comprehensive health insurance coverage is crucial for improving access to cancer care and outcomes, including stage at diagnosis and survival.

The Affordable Care Act expanded Medicaid coverage for people with low income in the United States. Expanded insurance coverage could promote more timely access to cancer treatment, which could improve overall survival (OS), yet the long‐term effects of Medicaid expansion (ME) remain unknown. We evaluated whether ME was associated with improved timely treatment initiation (TTI) and 3‐year OS among patients with breast, cervical, colon, and lung cancers who were affected by the policy.

Proposals for expanding Medicare insurance coverage to uninsured Americans approaching the Medicare eligibility age of sixty-five has been the subject of intense debate. We undertook this study to assess cancer survival differences between uninsured patients younger than age sixty-five and older Medicare beneficiaries by using data from the National Cancer Database from the period 2004-16. The main outcomes were survival at one, two, and five years for sixteen cancer types in 1,206,821 patients. We found that uninsured patients ages 60-64 were nearly twice as likely to present with late-stage disease and were significantly less likely to receive surgery, chemotherapy, or radiotherapy than Medicare beneficiaries ages 66-69, despite lower comorbidity among younger patients. Compared with older Medicare patients, younger uninsured patients had strikingly lower five-year survival across cancer types. For instance, five-year survival in younger uninsured patients with late-stage breast or prostate cancer was 5-17 percent lower than that among older Medicare patients. We conclude that survival after a diagnosis of cancer is considerably lower in younger uninsured patients than in older Medicare patients. Expanding comprehensive health insurance coverage to people approaching Medicare age eligibility may improve cancer outcomes in the US.

Health insurance coverage is a critical determinant of cancer care access. However, the association of different insurance statuses affecting survival outcomes remains understudied worldwide. This meta-analysis provides global evidence on the association between insurance status and survival and highlights structural health inequities across national health insurance systems. We searched five databases for cohort studies published between 1 January 2000 and 15 July 2025. Random-effect multilevel and traditional meta-analyses were employed to address heterogeneity. The Newcastle-Ottawa Scale (NOS) and the ROBINS-I method assessed all studies for quality. We included 37 studies between 2000 and 2025, contributing 219 effect sizes. In the United States (US), patients insured in Medicare (HR: 1.29, 95% CI: 1.17–1.42, P < 0.001; τ2(2) = 0.046, I2(2) = 67.28%; τ2(3) = 0.022, I2(3) = 31.89%), Medicaid (HR: 1.39; 95% CI: 1.28–1.51, P < 0.001; τ2(2) = 0.049, I2(2) = 74.07%; τ2(3) = 0.016, I2(3) = 24.60%), or without insurance (HR: 1.42, 95% CI: 1.31–1.53, P = 0.001; τ2(2) = 0.032, I2(2) = 65.99%; τ2(3) = 0.015, I2(3) = 30.77%) had worse overall survival (OS) than private insurers. Cancer stage, cancer type, and the adjustment variables are moderators of effect size heterogeneity in the US. The association between insurance status and survival was stronger in early-stage (I-II) cancers and among patients with breast and prostate cancer, whereas survival disparity across insurance statuses was smaller or not statistically significant for advanced (III-IV) stages and patients diagnosed with lung, liver, and colorectal cancer. In China, patients without Urban Employee Basic Medical Insurance (non-UEBMI) showed worse OS (HR: 1.39; 95% CI: 1.22–1.59; I2 = 60.0%; τ2 = 0.012) than UEBMI patients. Qualitative evidence from Germany, South Korea, Thailand, and Brazil did not identify statistically significant associations between insurance status and cancer survival outcomes. Uninsured individuals were experiencing poorer OS than those with any other form of insurance status globally. The association between insurance status and cancer survival differs across national health insurance systems. Insurance policies should prioritize early-stage cancer care, cancer types with a favorable prognosis, and uninsured groups. Future research should use prospective international cohorts to explore how insurance structures and covariate interactions affect survival and to achieve equity in global cancer care.

The impact of insurance status on survival outcomes in patients receiving first-line systemic therapy for metastatic renal cell carcinoma (mRCC) has not been explored. Herein, we aimed to determine whether insurance status affects progression-free survival (PFS) and overall survival (OS) in this setting. Patients diagnosed with mRCC between 1990 and 2022 from two National Cancer Institute–designated cancer centers with available insurance information were retrospectively identified using institutional databases. Patients were stratified by primary insurance type and secondary insurance status. PFS and OS were estimated by the Kaplan-Meier method and compared on the basis of insurance status using log-rank tests. Univariable and multivariable models were used to examine the impact of insurance status on survival outcomes. Of the 645 patients evaluated, 344 (53.3%), 250 (38.8%), and 51 (7.9%) had primary Medicare, private insurance, and Medicaid/no insurance, respectively. Compared with the Medicaid/no insurance group, patients with primary Medicare had significantly better PFS (hazard ratio [HR], 0.698 [95% CI, 0.502 to 0.971], P = .033), whereas patients with private insurance had similar PFS (HR, 1.017 [95% CI, 0.737 to 1.404], P = .917). Having secondary coverage was associated with significantly better PFS, but not OS, compared with primary coverage alone (HR, 0.812 [95% CI, 0.674 to 0.978], P = .028; HR, 1.025 [95% CI, 0.822 to 1.279], P = .824, respectively). Medicare was associated with lower risk of death compared with Medicaid/no insurance (HR, 0.495 [95% CI, 0.336 to 0.730], P < .001), whereas no significant difference in OS between private and Medicaid/no insurance groups was observed (HR, 0.955 [95% CI, 0.660 to 1.382], P = .807). In patients with mRCC, Medicare was associated with significantly better survival outcomes compared with Medicaid/no insurance and having secondary insurance was associated with better PFS compared with primary insurance alone. These results contribute to understanding cancer-related disparities and provide valuable data for devising solutions to address health care inequities.

Privately insured patients with head and neck cancer (HNC) typically have better outcomes; however, differential outcome among Medicaid versus the uninsured is unclear. We aimed to describe outcome disparities among HNC patients uninsured versus on Medicaid.

Background: The overall survival for small cell lung cancer (SCLC) patients at 5 years is only 5% to 10%, and improvements in treatment have proved to be unsatisfactory in prolonging SCLC survival. One of the challenges in improving cancer survival is identifying health disparities. In this study, we determined how disparities in payer status affected SCLC patient survival by analyzing data from the National Cancer Data Base (NCDB) between 1998 and 2011. Methods: We evaluated a cohort of 71,724 patients ages 18-65 diagnosed with stage III or IV SCLC who had not undergone surgery or hormonal therapy registered in the NCDB. Overall survival (OS) was the outcome variable, and payer status was the primary predictor variable. Multivariate Cox regression was used to investigate the effect of payer status on OS while adjusting for other factors. Results: The majority of patients diagnosed at stage III-IV had private insurance (57.93%), while 17.75%, 14.69% and 9.64% of patients had Medicare, Medicaid or were uninsured, respectively. Multivariate Cox regression analysis revealed a statistically significant relationship between payer status and overall survival when controlling for other variables. Uninsured, Medicaid, and Medicare patients were found to have a higher risk of death from SCLC compared to privately insured patients (p&amp;lt;.0001). The adjusted median OS of privately insured, uninsured, Medicare, and Medicaid patients was 10.32, 8.97, 9.00, and 9.00 months, respectively. Conclusions: Payer status proved to be a significant predictor of overall survival for SCLC, which remained true after adjusting for the other study variables. Uninsured, Medicaid, and Medicare patients had higher mortality compared to privately insured patients. Further study is needed to investigate the mechanism of payer status on survival of SCLC.

Healthcare disparities in colorectal cancer, driven by insurance status and socioeconomic factors, lead to delayed diagnoses and poor surgical outcomes. We sought to examine the impact of insurance status on presentation, treatment, and in-hospital mortality among CRC patients undergoing colectomy using the Nationwide Inpatient Sample (NIS) database. We included patients aged 18–65 years diagnosed with colon cancer and undergoing colectomy, as identified by ICD-9-CM codes. We classified them as those with private insurance, Medicaid, or no insurance during the period January 1, 2005, through December 31, 2014. The primary independent variable was insurance status, and the primary outcome was in-hospital postoperative death. Associations between this outcome and insurance status were analyzed using the Cox proportional hazard model, both in the full cohort as well as in a subset of patients with low comorbidity, with models stratified by hospitals to account for clustering effects from variations in access to care. The study cohort included 301,304 patients, of whom 238,158 (79.0%) were privately insured, 40,417 (13.4%) on Medicaid, and 22,729 (7.6%) were uninsured. Most patients were White (71.6%), followed by African American (12.6%), Hispanic (8.4%), Asian/Pacific Islander (3.8%), and Native American (0.5%). A total of 55.4% of cases took place in teaching hospitals. In the unadjusted analysis, the mortality rate for privately insured patients was 0.7% (95% CI 0.6–0.7%) compared with 2.1% for uninsured patients (95% CI 1.7–2.5%) and 1.5% for Medicaid recipients (95% CI 1.2–1.8%; p = 0.001). After adjusting for patient characteristics and stratifying by hospital in patients with low comorbidity, uninsured patients still had a higher risk of experiencing in-hospital death (HR, 1.60; 95% CI 1.24–2.07) compared with privately insured patients, while no significant disparity was found in Medicaid recipients (HR, 0.95; 95% CI 0.75–1.22). Uninsured patients undergoing colectomy for colon cancer experienced the highest in-hospital mortality, a disparity not fully explained by overall health differences. These findings underscore the critical role of insurance coverage in improving surgical outcomes and highlight the need for policy interventions to reduce mortality disparities. Supplementary Information The online version contains supplementary material available at 10.1038/s41598-025-21334-6.

Introduction: Previous studies have highlighted the association between insurance status and poor outcomes after surgical treatment of sarcomas in the United States.1-3 It is unclear how much of this disparity is mediated by confounding factors such as medical comorbidities and socioeconomic status and how much can be explained by barriers to care caused by insurance status. Methods: Surveillance, Epidemiology, and End Results-Medicare linkage data were procured for 7,056 patients undergoing treatment for bone and soft-tissue sarcomas in the extremities diagnosed between 2006 and 2013. A Cox proportional hazards model was used to assess the relative contributions of insurance status, medical comorbidities, tumor factors, treatment characteristics, and other demographic factors (race, household income, education level, and urban/rural status) to overall survival. Results: Patients with Medicaid insurance had a 28% higher mortality rate over the period studied, compared with patients with private insurance (hazard ratio, 1.28; 95% confidence interval, 1.03 to 1.60, P = 0.026), even when accounting for all other confounding variables. The 28% higher mortality rate associated with having Medicaid insurance was equivalent to being approximately 10 years older at the time of diagnosis or having a Charlson comorbidity index of 4 rather than zero (hazard ratio, 1.27). Discussion: Insurance status is an independent predictor of mortality from sarcoma, with 28% higher mortality in those with pre-expansion Medicaid.4,5 This association between insurance status and higher mortality held true even when accounting for numerous other confounding factors. Additional study is necessary into the mechanism for this healthcare disparity for the uninsured and underinsured, as well as strategies to resolve this inequality.

Previous studies found that uninsured and Medicaid insured cancer patients have poorer outcomes than cancer patients with private insurance. We examined the association between health insurance status and survival of New Jersey patients 18–64 diagnosed with seven common cancers during 1999–2004. Hazard ratios (HRs) with 95% confidence intervals for 5‐year cause‐specific survival were calculated from Cox proportional hazards regression models; health insurance status was the primary predictor with adjustment for other significant factors in univariate chi‐square or Kaplan–Meier survival log‐rank tests. Two diagnosis periods by health insurance status were compared using Kaplan–Meier survival log‐rank tests. For breast, colorectal, lung, non‐Hodgkin lymphoma (NHL), and prostate cancer, uninsured and Medicaid insured patients had significantly higher risks of death than privately insured patients. For bladder cancer, uninsured patients had a significantly higher risk of death than privately insured patients. Survival improved between the two diagnosis periods for privately insured patients with breast, colorectal, or lung cancer and NHL, for Medicaid insured patients with NHL, and not at all for uninsured patients. Survival from cancer appears to be related to a complex set of demographic and clinical factors of which insurance status is a part. While ensuring that everyone has adequate health insurance is an important step, additional measures must be taken to address cancer survival disparities.

Background: Cancer-specific mortality (CSM) is known to be higher among blacks and lower among Hispanics compared with whites. Private insurance confers CSM benefit, but few studies have examined the relationship between insurance status and racial disparities. We sought to determine differences in CSM between races within insurance subgroups. Methods: A population-based cohort of 577,716 patients age 18 to 64 years diagnosed with one of the 10 solid malignancies causing the greatest mortality over 2007 to 2012 were obtained from Surveillance, Epidemiology, and End Results. A Cox proportional hazards model for CSM was constructed to adjust for known prognostic factors, and interaction analysis between race and insurance was performed to generate stratum-specific HRs. Results: Blacks had similar CSM to whites among the uninsured [HR = 1.01; 95% confidence interval (CI), 0.96–1.05], but higher CSM among the Medicaid (HR = 1.04; 95% CI, 0.01–1.07) and non-Medicaid (HR = 1.14; 95% CI, 1.12–1.16) strata. Hispanics had lower CSM compared with whites among uninsured (HR = 0.80; 95% CI, 0.76–0.85) and Medicaid (HR = 0.88; 95% CI, 0.85–0.91) patients, but there was no difference among non-Medicaid patients (HR = 0.99; 95% CI, 0.97–1.01). Asians had lower CSM compared with whites among all insurance types: uninsured (HR = 0.80; 95% CI, 0.76–0.85), Medicaid (HR = 0.81; 95% CI, 0.77–0.85), and non-Medicaid (HR = 0.85; 95% CI, 0.83–0.87). Conclusions: The disparity between blacks and whites was largest, and the advantage of Hispanic race was absent within the non-Medicaid subgroup. Impact: These findings suggest that whites derive greater benefit from private insurance than blacks and Hispanics. Further research is necessary to determine why this differential exists and how disparities can be improved. Cancer Epidemiol Biomarkers Prev; 26(6); 869–75. ©2017 AACR.

… Multivariable Cox proportional hazard regression models were used to … of insurance status on all-cause and cancer-specific mortality in each calendar period. Proportionality of hazards …

… , both before and after controlling for variables identified in Cox proportional hazards modeling. Regression analyses were undertaken to identify the specific contribution of …

… cancer recurrence and mortality of patients diagnosed with squamous cell carcinoma of the head and neck are associated with insurance status, after adjusting for known cancer risk …

We assessed breast cancer mortality in older versus younger women according to race/ethnicity, neighborhood socioeconomic status (nSES), and health insurance status. The study included female breast cancer cases 18 years of age and older, diagnosed between 2005 and 2015 in the California Cancer Registry. Multivariable Cox proportional hazards modeling was used to generate hazard ratios (HR) of breast cancer specific deaths and 95% confidence intervals (CI) for older (60+ years) versus younger (< 60 years) patients separately by race/ethnicity, nSES, and health insurance status. Risk of dying from breast cancer was higher in older than younger patients after multivariable adjustment, which varied in magnitude by race/ethnicity (P-interaction< 0.0001). Comparing older to younger patients, higher mortality differences were shown for non-Hispanic White (HR = 1.43; 95% CI, 1.36–1.51) and Hispanic women (HR = 1.37; 95% CI, 1.26–1.50) and lower differences for non-Hispanic Blacks (HR = 1.17; 95% CI, 1.04–1.31) and Asians/Pacific Islanders (HR = 1.15; 95% CI, 1.02–1.31). HRs comparing older to younger patients varied by insurance status (P-interaction< 0.0001), with largest mortality differences observed for privately insured women (HR = 1.51; 95% CI, 1.43–1.59) and lowest in Medicaid/military/other public insurance (HR = 1.18; 95% CI, 1.10–1.26). No age differences were shown for uninsured women. HRs comparing older to younger patients were similar across nSES strata. Our results provide evidence for the continued disparity in Black-White breast cancer mortality, which is magnified in younger women. Moreover, insurance status continues to play a role in breast cancer mortality, with uninsured women having the highest risk for breast cancer death, regardless of age.

… in four deaths. … hazards model (Statistical Analysis) was tested using sensitivity analysis by categorizing patients with unknown insurance status as all having non-Medicaid insurance, …

Objectives: This study compared prevalence, incidence, mortality rates, treatment costs, and risk factors for oral and oropharyngeal cancer (OC/OPC) between two large cohorts of adults in 2012-2019. Methods: Medicaid and commercial claims data were from the IBM Watson Health MarketScan Database. Logistic regression analyses estimated incidence and risk factors for OC/OPC. Mortality was calculated by merging deceased individuals' Medicaid files with those of the existing cancer cohort. Costs were calculated by summing costs of outpatient and inpatient services. Results: The prevalence of OC/OPC in the Medicaid cohort decreased each year (129.8 cases per 100,000 enrollees in 2012 to 88.5 in 2019); commercial enrollees showed a lower and more stable prevalence (64.7 per 100,000 in 2012 and 2019). Incidence trended downward in both cohorts, with higher incidence in the Medicaid (51.4-37.6 cases per 100,000) than in the commercial cohort (31.9-31.0 per 100,000). OC/OPC mortality rates decreased in the Medicaid cohort during 2012-2014 but increased in the commercial cohort. Total OC/OPC treatment costs were higher for commercial enrollees by an average of $8.6 million during 2016-2019. In both cohorts, incidence of OC/OPC was higher among adults who were older, male, white, used tobacco or alcohol, or had prior HIV/AIDS diagnosis, and lower among those who had seen a dentist within the prior year. Conclusions: Medicaid enrollees experienced higher OC/OPC incidence, prevalence, and mortality compared with commercially insured adults. Having seen a dentist within the prior year was associated with a lower risk of OC/OPC diagnosis.

Abstract Background Disrupted and delayed Medicaid coverage has been consistently associated with lower rates of cancer screening and early-stage cancer diagnosis compared with continuous coverage. However, the relationships between Medicaid coverage timing, breast cancer treatment delays, and survival are less clear. Methods Using the linked Missouri Cancer Registry-Medicaid claims data, we identified 4583 women diagnosed with breast cancer between 2007 and 2016. We used logistic regression to estimate odds ratios (ORs) of late-stage diagnosis and treatment delays for prediagnosis (>30 days, >90 days, and >1 year before diagnosis) vs peridiagnosis enrollment. Cox proportional hazards models were used to estimate the hazard ratio (HR) of breast cancer-specific mortality for pre- vs postdiagnosis enrollment. Results Patients enrolled in Medicaid more than 30 days before diagnosis were less likely to be diagnosed at a late stage compared with those enrolled in Medicaid peridiagnosis (OR = 0.69, 95% confidence interval [CI] = 0.60 to 0.79). This result persisted using enrollment 90-day (OR = 0.64, 95% CI = 0.56 to 0.74) and 1-year thresholds (OR = 0.55, 95% CI = 0.47 to 0.65). We did not observe a difference in the likelihood of treatment delays between the 2 groups. After adjustment for sociodemographic factors, there was no statistically significant difference in the risk of breast cancer mortality for patients enrolled more than 30 days prediagnosis relative to patients enrolled peridiagnosis (HR = 0.98, 95% CI = 0.83 to 1.14), but a lower risk was observed for patients enrolled prediagnosis when using 90 days (HR = 0.85, 95% CI = 0.72 to 0.999) or 1 year (HR = 0.79, 95% CI = 0.66 to 0.96) as the threshold. Conclusions Women with breast cancer who enroll in Medicaid earlier may benefit from earlier diagnoses, but only longer-term enrollment may have survival benefits.

Key Points Question Is Medicaid expansion under the Patient Protection and Affordable Care Act associated with lower overall mortality among women with breast cancer? Findings In a cohort study of 1 595 845 women aged 40 to 64 years with breast cancer, Medicaid expansion was associated with lower overall mortality. Lower mortality was observed across disease stage, race and ethnicity, neighborhood income, and treatment strata, with the largest relative gains among Hispanic women and with smaller gains among non-Hispanic Black women and residents of low-income areas. Meaning The findings of this study suggest that Medicaid expansion was associated with improved survival among women with breast cancer, although the benefits were not equitably distributed.

Relative survival and disease-specific survival are two statistics that measure net survival from a cancer diagnosis, excluding other causes of death. In most cases, these two rates are comparable. However, in some cancer types for which cancer screening is performed, relative survival is often greater than disease-specific survival. This divergence has been attributed to mechanisms such as the "healthy user effect" and overdiagnosis of indolent tumors detected by screening. Using relative survival rate as a marker of these mechanisms, we examined the association of breast cancer screening with relative survival rates for women diagnosed with early-stage breast cancer. In population-based data from the National Cancer Institute's Surveillance, Epidemiology and End Results registry, we examined relative survival rates in women diagnosed with stage I breast cancer or ductal carcinoma in situ who were in highly screened vs less-highly screened groups, based on time period, age group, and insurance status. In this analysis, relative survival rates for early-stage breast cancer were higher than disease-specific survival, even exceeding 100% in populations experiencing higher rates of screening (ie, women diagnosed during the era of widespread uptake of mammography, age older than 40 years, and women with health insurance coverage). The favorable outcomes observed in screen-detected breast cancers are at least in part attributable to the healthy user effect and overdiagnosis of indolent tumors. Therefore, survival rates may not accurately reflect the effectiveness of cancer screening. These findings have implications for counseling of patients and future clinical studies of active monitoring approaches in breast cancer.

… breast cancer (LABC). We assessed LABC rates pre- and post-Medicaid expansion, and evaluated overall survival (… uninsured in states that chose not to expand Medicaid. In addition, …

… breast cancer (LABC). We assessed LABC rates pre- and post-Medicaid expansion, and evaluated overall survival (… uninsured in states that chose not to expand Medicaid. In addition, …

Background: Medicare and Medicaid dually eligible beneficiaries (duals) could experience Medicaid coverage changes without losing Medicaid. It is unknown whether health care use and clinical outcomes among elderly duals with coverage changes would be like those among duals without coverage changes or duals ever lost Medicaid and whether various types of unstable coverage due to income/asset changes are associated with worse clinical outcomes. Objectives: Examine the associations of unstable Medicaid coverage with clinical outcomes among older Medicare beneficiaries. Research Design: Population-based cohort study. Subjects: A total of 131,202 women newly diagnosed with breast cancer at 65 years and older between 2007 and 2015 were identified from the Surveillance, Epidemiology, and End Results-Medicare linked database. Measures: We examined 2 types of unstable Medicaid coverage: (1) those who had changes in the types of Medicaid support they received and (2) those who ever lost Medicaid. We examined outcomes that predict better cancer survival and involve the use of inpatient and outpatient services and prescription drugs: early diagnosis, receiving surgery, receiving radiation, hormonal therapy adherence, and discontinuation. We used logistic regressions to estimate the predicted probabilities of outcomes for dual groups. Results: Duals had poorer outcomes than those who were “never dual.” Women with the 2 types of unstable Medicaid coverage had similarly worse outcomes than those with stable coverage. Those with stable coverage had similar outcomes regardless of the generosity of Medicaid support. Conclusions: These patterns are concerning and, in the context of well-defined clinical guidelines for beneficial treatments that extend survival, point to the importance of stable insurance coverage and income.

BACKGROUND Hormone receptor (HR)-negative, HER2-positive (also called HER2-enriched) breast cancer has no worse prognosis than other breast cancers if it is treated with HER2-targeted therapy. Medicaid expansion under the Affordable Care Act (ACA) has been shown to be associated with improved access to care and outcomes for many cancers, but its association with receipt of care for HR-negative, HER2-positive breast cancer is unknown. We examined the association of Medicaid expansion with receipt of guideline-concordant treatment, time to treatment initiation, and survival among nonelderly women newly diagnosed with HR-negative, HER2-positive breast cancer. PATIENTS AND METHODS Women aged 18 to 62 years newly diagnosed with HR-negative, HER2-positive breast cancer between 2010 and 2018 were identified from the National Cancer Database. Outcomes included receipt of stage-based guideline-concordant treatment, timely initiation of treatment (<30 days, <60 days, <90 days from diagnosis), and stage-specific 2-year overall survival. A difference-in-differences (DID) analytic approach compared outcome changes following Medicaid expansion in expansion versus nonexpansion states. Multivariable linear probability models were used to estimate treatment outcomes, and flexible parametric survival models were used to evaluate survival, adjusting for sociodemographic and clinical confounders. RESULTS A total of 31,401 patients were included. Medicaid expansion was associated with an increase of 0.58 percentage points (ppt; 95% CI, 0.01-1.16) in receipt of guideline-concordant treatment overall, a 2.43-ppt (95% CI, 0.68-4.18) increase in initiating guideline-concordant treatment <60 days after diagnosis, and a 1.17-ppt (95% CI, 0.02-2.32) increase in 2-year survival rate. The increase in 2-year survival associated with Medicaid expansion was most prominent for patients with stage III disease (DID, 3.81; 95% CI, 0.82-6.80). CONCLUSIONS Medicaid expansion was associated with improved care and survival for patients with HR-negative, HER2-positive breast cancer, an aggressive cancer type for which prognosis largely depends on access to effective treatment.

BACKGROUND The objective of this study was to evaluate the impact of Medicaid expansion on breast cancer treatment and survival among Medicaid-insured women in Ohio, accounting for the timing of enrollment in Medicaid relative to their cancer diagnosis and post-expansion heterogeneous Medicaid eligibility criteria, thus addressing important limitations in previous studies. METHODS Using 2011-2017 Ohio Cancer Incidence Surveillance System data linked with Medicaid claims data, we identified women aged 18 to 64 years diagnosed with local-stage or regional-stage breast cancer (n=876 and n=1,957 pre-expansion and post-expansion, respectively). We accounted for women's timing of enrollment in Medicaid relative to their cancer diagnosis, and flagged women post-expansion as Affordable Care Act (ACA) versus non-ACA, based on their income eligibility threshold. Study outcomes included standard treatment based on cancer stage and receipt of lumpectomy, mastectomy, chemotherapy, radiation, hormonal treatment, and/or treatment for HER2-positive tumors; time to treatment initiation (TTI); and overall survival. We conducted multivariable robust Poisson and Cox proportional hazards regression analysis to evaluate the independent associations between Medicaid expansion and our outcomes of interest, adjusting for patient-level and area-level characteristics. RESULTS Receipt of standard treatment increased from 52.6% pre-expansion to 61.0% post-expansion (63.0% and 59.9% post-expansion in the ACA and non-ACA groups, respectively). Adjusting for potential confounders, including timing of enrollment in Medicaid, being diagnosed in the post-expansion period was associated with a higher probability of receiving standard treatment (adjusted risk ratio, 1.14 [95% CI, 1.06-1.22]) and shorter TTI (adjusted hazard ratio, 1.14 [95% CI, 1.04-1.24]), but not with survival benefits (adjusted hazard ratio, 1.00 [0.80-1.26]). CONCLUSIONS Medicaid expansion in Ohio was associated with improvements in receipt of standard treatment of breast cancer and shorter TTI but not with improved survival outcomes. Future studies should elucidate the mechanisms at play.

PURPOSE De novo metastatic breast cancer (dnMBC) is typically a fatal diagnosis. Although better treatments have improved survival, it is unclear whether these improvements confer similar benefits for all patients. We sought to evaluate the association of race/ethnicity and insurance status with survival outcomes in patients with dnMBC. METHODS Patients diagnosed with dnMBC between 1988 and 2016 were selected from SEER. Differences were examined by race/ethnicity (non-Hispanic White [NHW], non-Hispanic Black [NHB], non-Hispanic other [NHO], or Hispanic) and insurance status (private/Medicare, Medicaid, or uninsured). Overall survival (OS) and cancer-specific survival were estimated, and multivariable models were used to identify factors associated with survival, after adjustment. RESULTS 47,034 patients were included (median follow-up, 91 months). Most patients were NHW (67.2%) and insured (73.9%). Overall, NHB patients had the worst outcomes (median OS, 21 months), while NHO patients had the best (34 months). Similarly, uninsured patients had the worst survival outcomes (22 months), while insured (private/Medicare) patients had the best (31 months). Over time, survival generally improved across all groups, although disparities persisted. After adjustment, only NHB patients had significantly worse outcomes compared with NHW patients (OS: hazard ratio [HR], 1.24 [95% CI, 1.17 to 1.31]; P < .001), as did uninsured compared with insured patients (OS: HR, 1.29 [95% CI, 1.16 to 1.44]; P < .001). CONCLUSION Racial/ethnic and insurance disparities in breast cancer survival persist, even in a dnMBC-only cohort, with notably worse outcomes for NHB and uninsured patients. Given that race and ethnicity are often considered social constructs in the United States specifically, improving health care access has the potential to improve survival in this patient population. Systemic factors other than insurance status leading to disparities must be identified and addressed to provide equitable treatment in this vulnerable patient population.

Background Although incidence and mortality of lung cancer have been decreasing, health disparities persist among historically marginalized Black, Hispanic, and Asian populations. A targeted literature review was performed to collate the evidence of health disparities among these historically marginalized patients with lung cancer in the U.S. Methods Articles eligible for review included 1) indexed in PubMed®, 2) English language, 3) U.S. patients only, 4) real-world evidence studies, and 5) publications between January 1, 2018, and November 8, 2021. Results Of 94 articles meeting selection criteria, 49 publications were selected, encompassing patient data predominantly between 2004 and 2016. Black patients were shown to develop lung cancer at an earlier age and were more likely to present with advanced-stage disease compared to White patients. Black patients were less likely to be eligible for/receive lung cancer screening, genetic testing for mutations, high-cost and systemic treatments, and surgical intervention compared to White patients. Disparities were also detected in survival, where Hispanic and Asian patients had lower mortality risks compared to White patients. Literature on survival outcomes between Black and White patients was inconclusive. Disparities related to sex, rurality, social support, socioeconomic status, education level, and insurance type were observed. Conclusions Health disparities within the lung cancer population begin with initial screening and continue through survival outcomes, with reports persisting well into the latter portion of the past decade. These findings should serve as a call to action, raising awareness of persistent and ongoing inequities, particularly for marginalized populations.

Supplemental Digital Content is available in the text. Background: Annual lung cancer screening via low-dose computed tomography can reduce lung cancer mortality among high-risk adults by 20%; however, screening take-up remains low. Inadequate insurance coverage or access to care may be a barrier to screening. Objective: The objective of this study was to estimate the effect of nearly universal access to Medicare coverage on annual lung cancer screening. Research Design: A regression discontinuity design was used to estimate the causal effect of nearly universal access to Medicare at age 65. Data come from the 2017 to 2019 Behavioral Risk Factor Surveillance System in 28 states that adopted the optional module on lung cancer screening and lung cancer risk. Subjects: A total of 11,163 individuals at high risk for lung cancer just above and below age 65. Measure: Self-reported use of low-dose computed tomography to screen for lung cancer in the past 12 months. Results: A total of 10,951 people at high lung cancer risk (45.7% women, response rate=98.1%) reported lung cancer screening information. Nearly universal access to Medicare increased lung cancer screening by 16.2 percentage points among men (95% confidence interval: 2.4%–30.0%, P=0.02), compared with a baseline screening rate of 11.1% just younger than age 65. Women had a baseline screening rate of 18.2% and experienced no statistically significant change in screening (1.6 percentage point increase, 95% confidence interval: −19.8% to 23.0%, P=0.88). Conclusions: Gaining Medicare coverage at age 65 increased lung cancer screening take-up among men at high lung cancer risk. Lack of insurance or inadequate access to care hinders screening.

Key Points Question Is geographic access to cancer care associated with guideline-recommended treatment for early-stage non–small cell lung cancer (NSCLC) and outcomes? Findings In a population-based cohort study of 65 259 patients with early-stage NSCLC, those living in counties with the least (vs greatest) access to thoracic surgeons and radiation oncologists were more likely to die. The association between geographic access to lung cancer care and guideline-concordant treatment was stronger in older, Hispanic, Asian, uninsured, and Medicaid-insured patients. Meaning These findings suggest that interventions targeting geographic barriers to lung cancer care could improve NSCLC treatment, prognosis, and equity.

Key Points Question Was the introduction of immune checkpoint inhibitors (ICIs) associated with increased disparities in survival by health insurance coverage among individuals with a new diagnosis of advanced-stage cancer? Findings This serial cross-sectional study using nationwide cancer registry data found that after the introduction of ICIs, there was a statistically significant widening of the gap in survival outcomes between privately insured and uninsured individuals with a new diagnosis of stage IV melanoma, non–small cell lung cancer, or renal cell carcinoma. Meaning This study suggests that programs aimed at improving health insurance coverage and providing comprehensive financial assistance to people without coverage may help to mitigate disparities in survival among individuals with a new diagnosis of advanced-stage cancer.

… and longer survival than people without insurance. Patients with … In addition, health insurance can increase lung cancer … of health insurance coverage to those who are uninsured would …

Objectives Safety-net hospitals deliver a significant level of care to uninsured patients, Medicaid-enrolled patients, and other vulnerable patients. Little is known about the impact of safety-net hospital status on outcomes in non–small cell lung cancer. We aimed to compare treatment characteristics and outcomes between hospitals categorized according to their relative burden of uninsured or Medicaid-enrolled patients with non–small cell lung cancer. Methods We queried the National Cancer Database for patients with clinical stage I and II non–small cell lung cancer presenting from 2004 to 2018. We categorized hospitals on the basis of their relative burden of uninsured or Medicaid-enrolled patients with non–small cell lung cancer into low-burden (<8.2%), medium-burden (8.2%-12.0%), high-burden (12.1%-16.8%), and highest burden (>16.8%) quartiles. We investigated the impact of care at these hospitals on outcomes while controlling for sociodemographic, clinical, and facility characteristics. Results We identified 204,189 patients treated at 1286 facilities. There were 592 low-burden, 297 medium-burden, 219 high-burden, and 178 highest burden hospitals. Patients at highest burden hospitals were more likely to be younger, male, Black, and Hispanic (P < .01), and to reside in rural, low-income, and low-educated regions (P < .01). Patients at these facilities had a greater likelihood of not receiving surgery, undergoing an open procedure, undergoing a regional lymph node examination involving less than 10 lymph nodes, having a length of stay more than 4 days, and not receiving treatment (P < .05). Conclusions Our results indicate reduced treatment quality and higher mortality in patients undergoing surgery for early non–small cell lung cancer at hospitals with an increased burden of uninsured or Medicaid-enrolled patients with non–small cell lung cancer. There is a need to raise the standard of care to improve outcomes in vulnerable populations.

… the survival benefits of universal health care system to lung … vary in insurance status/ type, which itself is related to cancer … shown that lung cancer patients without health insurance or …

BACKGROUND Evidence suggests that patients with Medicaid experience lower-quality cancer care than those with commercial insurance. Whether this trend persists in the era of personalized medicine is unclear. This study examined the associations between Medicaid (vs commercial) insurance and receipt of biomarker testing, targeted therapy, and overall survival in patients with advanced non-small cell lung cancer (aNSCLC). METHODS We conducted a retrospective study of patients who received an aNSCLC diagnosis from January 2011 to September 2019 using a nationwide US healthcare database. Eligible patients were aged 18 to 64 years with Medicaid or commercial insurance at diagnosis. Receipt of biomarker testing (ALK, EGFR, ROS1, BRAF, and PD-L1) was assessed. The likelihood of testing, biomarker-driven therapy (cancer immunotherapy or tyrosine kinase inhibitor treatment), and mortality were compared by insurance type using adjusted Cox regression. RESULTS Our sample included 6,145 commercially insured and 865 Medicaid beneficiaries. Medicaid beneficiaries were more likely to be Black or African American (20% vs 9.3%; P <.001) and were less likely to have undergone biomarker testing (57% vs 71%; P <.001). In the adjusted analysis, Medicaid beneficiaries were less likely to have evidence of testing (hazard ratio [HR], 0.81; P <.001), any first-line treatment (HR, 0.72; P <.001), and first-line biomarker-driven therapy (HR, 0.70; P <.001). Medicaid beneficiaries with evidence of biomarker testing had a lower risk of death compared with those without evidence of biomarker testing (HR, 1.27 [95% CI, 1.06-1.52]; P =.010). Higher risk of death was observed in patients with Medicaid versus commercially insured patients (HR, 1.23; P <.001); this result remained unchanged after adjusting for biomarker testing (HR, 1.22; P < .001) but was partially ameliorated after adjustment for testing and treatment type (HR, 1.12; P =.010). CONCLUSIONS Medicaid beneficiaries with aNSCLC were less likely to receive biomarker testing and biomarker-driven therapies, which may in part contribute to a higher observed risk of mortality compared with commercially insured patients.

A Medicare effect has been described to account for increased health care utilization occurring at the age of 65 years. The existence of such an effect in cancer care, where it would be most likely to reduce mortality, has been unclear.

… Medicaid expansion is associated with decreased uninsured rates … The Affordable Care Act (ACA) provided states the … cancer mortality changes associated with the early Medicaid …

Key Points Question Is Medicaid expansion under the Patient Protection and Affordable Care Act associated with improvement in postoperative survival among patients with non–small cell lung cancer (NSCLC)? Findings In this cohort study assessing 14 984 adults 45 to 64 years of age with NSCLC identified in the National Cancer Database, Medicaid expansion was associated with a significant reduction in 30- and 90-day mortality after discharge from the hospital following surgical resection of stage I to III NSCLC. Meaning These results suggest that during a period when access to care is crucial (ie, recovery from major surgery), Medicaid expansion may be associated with improved survival.

Medicaid expansion is associated with improvements in access to early detection and treatment services, and 2-year overall survival (OS) among individuals with cancer. However, the association with improvements in longer-term survival remains understudied. A difference-in-differences (DD) approach was used to examine changes in 5-year cause-specific survival and OS following Medicaid expansion. A total of 1,423,983 cancer cases diagnosed between 2007 and 2008 and 2014 and 2015 among adults 18 to 59 years of age residing in 26 expansion and 12 non-expansion states were included. Improvements in cause-specific survival were significantly greater in expansion states among individuals residing in rural [DD: 2.55 percentage point (ppt); 95% confidence interval (CI), 0.23-4.86] and high-poverty communities (DD: 1.54 ppt; 95% CI, 0.30-2.77), non-Hispanic White individuals (DD: 0.37 ppt; 95% CI, 0.05-0.70), and those with pancreatic (DD: 2.60 ppt; 95% CI, 0.86-4.34), lung (DD: 1.32 ppt; 95% CI, 0.30-2.34), and colorectal cancers (DD: 1.31 ppt; 95% CI, 0.26-2.37). Results were similar for OS. These findings underscore the importance of Medicaid expansion in mitigating disparities in survival outcomes. SIGNIFICANCE Improvements in 5-year cause-specific survival and OS were greater in Medicaid expansion than non-expansion states among individuals residing in rural and high-poverty communities and among individuals diagnosed with cancers that generally have a worse prognosis, emphasizing the importance of Medicaid expansion in mitigating disparities in survival outcomes.

BACKGROUND The Affordable Care Act's Medicaid expansion is associated with earlier diagnosis and improved care among lower socioeconomic status populations with cancer, but its impact on melanoma is undefined. OBJECTIVE To determine the association of Medicaid expansion with stage of diagnosis and utilization of sentinel lymph node biopsy (SLNB) in non-elderly adult patients with newly diagnosed clinically localized melanoma. METHODS Quasi-experimental, difference-in-differences retrospective cohort analysis using data from the National Cancer Database from 2010 to 2017. Patients from expansion versus non-expansion states and diagnosed before (2010-13) versus after (2014-17) expansion were identified. RESULTS Of 83,322 patients, 46.6% were female, and the median age was 55 (interquartile range 49-60) years. Following risk adjustment, Medicaid expansion was associated with a decrease in the diagnosis of ≥T1b stage melanoma (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.88-0.98, P=0.011) and decrease in uninsured status (OR 0.61, 95% CI 0.52-0.72, P<0.001), but was not associated with a difference in SLNB performance when indicated (OR 1.06, 95% CI 0.95-1.20, P=0.29). LIMITATIONS Retrospective study using a national database. CONCLUSION In this study of patients with clinically localized melanoma, Medicaid expansion was associated with a decrease in the diagnosis of later T-stage tumors.

Abstract Introduction: Following passage of the Affordable Care Act, Medicaid access was expanded in several states beginning in 2014. We sought to determine the oncologic implications by comparing outcomes between testicular germ cell tumor patients with Medicaid and those without insurance, and by assessing for changes in outcomes after 2014. Methods: A total of 18,506 men with seminomatous or nonseminomatous germ cell tumors were identified within the Surveillance, Epidemiology, and End Results database (2007–2016). Multivariable Cox proportional hazards, Fine and Gray competing-risks regression, propensity score matching, cumulative incidence plots and segmented Poisson regression models were used. Results: Compared to no insurance, Medicaid insurance was not associated with differences in all-cause mortality or cancer-specific mortality among seminoma patients (all-cause mortality: HR=1.24, p=0.87; cancer-specific mortality: HR=0.92, p=0.75) or nonseminoma patients (all-cause mortality: HR=1.13, p=0.33; cancer-specific mortality: HR=1.10, p=0.51). Among matched Medicaid and uninsured patients, there was again no difference in cancer-specific mortality for those with seminoma (p=0.81) or nonseminoma (p=0.23). There was a 99% increase in Medicaid enrollment in expansion states in the post-Affordable Care Act era. There was no difference in post-expansion all-cause mortality between expansion states and nonexpansion states for men with seminoma (p=0.42) or nonseminoma (p=0.53). Conclusions: Medicaid enrollment increased in expansion states following the Affordable Care Act. However, there was no difference in survival between Medicaid patients and uninsured patients, or between patients in expansion states versus nonexpansion states, highlighting the need for population-level policy interventions to improve access and quality of care among testicular cancer patients with Medicaid.

Key Points Question Is the Patient Protection and Affordable Care Act’s Medicaid expansion associated with the presentation and management of genitourinary cancers? Findings In this case-control study including 340 552 patients with newly diagnosed genitourinary cancer in the National Cancer Database from 2011 to 2016, a difference-in-difference analysis found that, compared with states that did not expand Medicaid, Medicaid expansion was significantly associated with a decreased uninsured rate, an increased proportion of early-stage diagnosis for kidney and prostate cancers, and an increased proportion of patients receiving active surveillance for low-risk prostate cancer, with larger magnitudes of association observed in the low-income population. Meaning These findings suggest that Medicaid expansion was associated with downstream diagnosis and treatment outcomes for genitourinary malignant neoplasms and may reduce socioeconomic disparities in these metrics.