Payer Status Influence on Presenting Stage of Breast Cancer at a Community Teaching Hospital Cancer Program

Breast cancer is a costly disease, averaging $40,000 in the first year of diagnosis alone.1 The prognosis of breast cancer is directly related to stage at pre- sentation. Having health insurance and the type of insurance used have been shown to be predictive of access to care and screening services.2 As documented by Roetzheim et al,2 patients who lack health insurance and those who are insured by Medicaid are more likely diagnosed with later stages of cancer (odds ratio, 1.87; P < 0.001). Their data also showed that patients who were non-Hispanic black or Hispanic were more likely to be diagnosed at a late stage independent of their in- surance payer.

Wang et al.3 performed a study of the population specific to Illinois indicating ''that people living in areas with a high concentration of disadvantaged populations (i.e., low-income groups and racial or ethnic minorities) are more likely to be diagnosed with late-stage breast cancer.'' Another study by Halpern et al.4 showed evidence that those with Medicaid or no insurance were more likely to pres- ent with advanced-stage breast cancer. The shift in distribution toward a more advanced stage is at- tributed to lack of use of mammography and delays in diagnosis.

Screening for breast cancer detects premalignant and early lesions and favorably impacts mortality. The prognosis of breast cancer is directly related to stage at presentation. We sought to determine the relationship between presenting stage and insurance status.

An Institutional Review Board-approved retro- spective query of the breast cancer database from 1990 to 2010 was performed and identified patients diagnosed with early-stage breast cancer, defined as size less than 4 cm and N0 or N1, at a regional medical center that serves as a Teaching Hospital Cancer Program as approved by the American Col- lege of Surgeons Commission on Cancer. Patient factors included ethnicity (white, black, and other) and payer source. Insurance types were divided into government (Medicaid, Medicare), private, and self- pay. Data were described using frequencies. The Cochran-Mantel-Haenszel test was used to compare stage at diagnosis to insurance status while control- ling for race. Analysis was performed using SAS 9.1 (SAS Institute, Cary, NC). A P value < 0.05 was considered significant.

There were 3375 patients in the registry with early- stage breast cancer. The study population was 84.41 per cent white, 14.28 per cent black, and 1.01 per cent other races (0.30% of patients had no recorded race; Table 1). Of the study population, 27.88 per cent were with Medicare, 4.83 per cent with Medic- aid, 1.78 per cent dually enrolled in Medicaid and Medicare, 61.90 per cent with private insurance, and 3.11 per cent patients were self-pay (payer status was unknown or missing for 0.51% of patients). To strengthen the analysis, patients of other or unknown races were not included nor were patients with un- known payer status.

In comparing Medicaid, Medicare, self-pay, and private insurance, we found that when controlling for race, the stage at which cancer was diagnosed was significantly different depending on payer status (Cochran-Mantel-Haenszel, P 4 0.0001). In this analysis, dually enrolled Medicare and Medicaid pa- tients were excluded.

Stage 0 breast cancer was diagnosed in 12.74 per cent of Medicaid patients as compared with 18.45 per cent of privately insured patients, 21.02 per cent of Medicare patients, and 20.00 per cent of self-pay patients (Fig. 1).

Stage 2 breast cancer was diagnosed in 40.13 per cent of Medicaid patients as compared with 33.29 per cent of privately insured patients, 25.40 per cent of Medicare patients, and 33.33 per cent of self-pay patients.

At our institution, which serves a city of over 100,000 and has a catchment area of over 500,000 people, payer status was found to influence the stage of breast cancer at presentation. The majority of the patients in our study population were white. The largest insurance designation overall was that of private in- surance. Of those with government insurance or no in- surance, the largest designation was Medicare.

Stage II breast cancer was more likely to be di- agnosed in Medicaid patients than any other insurance designation, including self-pay. We suspect this is the result of lack of use of screening mammograms or lack of access to care altogether. Further research needs to be performed examining the time course of diagnosis in the advanced-stage population. Surveying patients di- agnosed with advanced-stage breast cancer as to whether they were undergoing age-appropriate rou- tine screening or if they had impediments to gaining access to medical care would reveal possible areas for improvement in the healthcare system. It would be in- teresting to examine the barriers to care according to insurance status as well.

In conclusion, patients with Medicaid are more likely to be diagnosed at a higher stage at presen- tation. Every effort must be made to educate all, and especially Medicaid patients, about the importance of appropriate breast cancer screening. Providers caring for the Medicaid population should be con- scious of the availability and use of resources for breast cancer screening and diagnosis by this specific population.

REFERENCES

1. Henry RE. Highlights from ASCO 2010: An update on breast cancer for payers and pharmacists. American Health & Drug Benefits for Payers, Purchasers, Policymakers, and Other Health- care Stakeholders 2010;3:S321-9.

2. Roetzheim RG, Pal N, Tennant C, et al. Effects of health insurance and race on early detection of cancer. J Natl Cancer Inst 1999;91:1409-15.

3. Wang F, McLafferty S, Escamilla V, et al. Late-stage breast cancer diagnosis and health care access in Illinois. Prof Geogr 2008;60:54-69.

4. Halpern MT, Bian J, Ward EM, et al. Insurance status and stage of cancer at diagnosis among women with breast cancer. Cancer 2007;110:403-11.

Presented at the Southeastern Surgical Congress, Birmingham, AL, February 2012.

Address correspondence and reprint requests to Cyrus A. Kotwall, M.D., Department of Surgery, South East Area Health Education Center, New Hanover Regional Medical Center, Wilmington, NC, 2131 S. 17th Street, P.O. Box 9025, Wilmington, NC 28402. E-mail: canuck@med.unc.edu.

Cyrus A. Kotwall, M.D.

Department of Surgery

South East Area Health Education Center

New Hanover Regional Medical Center

Wilmington, North Carolina

Mindy L. Merritt, M.D.

Department of Surgery

South East Area Health Education Center

New Hanover Regional Medical Center&lt;/p>

Wilmington, North Carolina; and

University of North Carolina at Chapel Hill School of Medicine

Wilmington, North Carolina

Sarah N. Kilbourne, B.Sc.

South East Area Health Education Center

Wilmington, North Carolina; and

North Carolina State University

Raleigh, North Carolina

Ashley R. Adams, B.A.

South East Area Health Education Center

Wilmington, North Carolina