BACKGROUNDSentinel lymph node biopsy (SLNB), an acceptable alternative to axillary lymph node dissection for staging patients with breast cancer, was introduced to clinical practice in the late 1990s. We assessed demographic, clinical, and facility-related factors associated with SLNB in women with early-stage breast cancer and evaluated trends in these factors over time.METHODSData on early-stage breast cancers (T1a, T1b, T1c, and T2N0) diagnosed between January 1, 1998, and December 31, 2005, were extracted from the National Cancer Database, a hospital-based registry. Patient demographics, tumor stage, type of lymph node surgery, type of breast cancer surgery, health insurance, treatment facility type, and area-level education and income variables were collected. Multivariable logistic regression analyses were performed to assess predictive factors associated with SLNB, temporal differences in factors associated with SLNB, and differences in rates of SLNB by facility type, race/ethnicity, and type of health insurance over time.RESULTSThe total analytic study population included 490,899 women. The use of SLNB increased from 26.8% in 1998 to 65.5% in 2005. Factors associated with lower likelihood of SLNB over the study period included being older (odds ratio [OR] = 0.80, 95% confidence interval [CI] = 0.78 to 0.92 for those aged 72 or older compared with those aged 51 or younger), being of racial/ethnic minority (OR = 0.76, 95% CI = 0.74 to 0.78 for African Americans compared with whites), having no health insurance (OR = 0.77, 95% CI = 0.73 to 0.80 for uninsured compared with having private insurance), having certain government insurance plans (for Medicaid, OR = 0.81, 95% CI = 0.78 to 0.84, and for Medicare at age <65 years, OR = 0.83, 95% CI = 0.80 to 0.87, both compared with private insurance), residing in zip codes with lower proportion of high school graduates (OR = 0.88, 95% CI = 0.86 to 0.89) or with lower median income (OR = 0.79, 95% CI = 0.77 to 0.81), and receiving treatment in facility types other than a teaching or research hospital (for community hospital, OR = 0.84, 95% CI = 0.82 to 0.86; for community cancer center, OR = 0.86, 95% CI = 0.84 to 0.87). The associations with insurance status and sociodemographic characteristics were more pronounced in 2005 than in 1998. For example, the adjusted annual rates of SLNB in 1998 were 0.29 in whites, 0.26 in African Americans, and 0.35 in Hispanics; in 2005 the respective rates were 0.70, 0.64, and 0.67.CONCLUSIONSAlthough use of SLNB increased from 1998 to 2005, disparities persisted in receipt of SLNB that are based on nonclinical factors, including sociodemographic characteristics and insurance status.

BACKGROUND:Individuals in the USA without private medical insurance are less likely to have access to medical care or participate in cancer screening programmes than those with private medical insurance. Smaller regional studies in the USA suggest that uninsured and Medicaid-insured individuals are more likely to present with advanced-stage cancer than privately insured patients; however, this finding has not been assessed using contemporary, national-level data. Furthermore, patients with cancer from ethnic minorities are more likely to be uninsured or Medicaid-insured than non-Hispanic white people. Separating the effects on stage of cancer at diagnosis associated with these two types of patient characteristics can be difficult.METHODS:Patients with cancer in the USA, diagnosed between 1998 and 2004, were identified using the US National Cancer Database-a hospital-based registry that contains patient information from about 1430 facilities. Odds ratios and 95% CIs for the effect of insurance status (Medicaid, Medicare (65-99 years), Medicare (18-64 years), private, or uninsured) and ethnicity (white, Hispanic, black, or other) on disease stage at diagnosis for 12 cancer sites (breast [female], colorectal, kidney, lung, melanoma, non-Hodgkin lymphoma, ovary, pancreas, prostate, urinary bladder, uterus, and thyroid) were estimated, while controlling for patient characteristics.FINDINGS:3,742,407 patients were included in the analysis; patient characteristics were similar to those of the corresponding US population not included in the analysis. Uninsured and Medicaid-insured patients were significantly more likely to present with advanced-stage cancer compared with privately insured patients. This finding was most prominent for patients who had cancers that can potentially be detected early by screening or symptom assessment (eg, breast, colorectal, and lung cancer, as well as melanoma). For example, the odds ratios for advanced-stage disease (stage III or IV) at diagnosis for uninsured or Medicaid-insured patients with colorectal cancer were 2.0 (95% CI 1.9-2.1) and 1.6 (95% CI 1.5-1.7), respectively, compared with privately-insured patients. For advanced-stage melanoma, the odds ratios were 2.3 (2.1-2.5) for uninsured patients and 3.3 (3.0-3.6) for Medicaid-insured patients compared with privately insured patients. Black and Hispanic patients were noted to have an increased risk of advanced-stage disease (stage III or IV) at diagnosis, irrespective of insurance status, compared with White patients.INTERPRETATION:In this US-based analysis, uninsured and Medicaid-insured patients, and those from ethnic minorities, had substantially increased risks of presenting with advanced-stage cancers at diagnosis. Although many factors other than insurance status also affect the quality of care received, adequate insurance is a crucial factor for receiving appropriate cancer screening and timely access to medical care.

Background. This report evaluated the association between surviving pediatric cancer and receiving a diagnosis of a stress-related mental disorder (SRMD) (i.e., post-traumatic stress disorder (PTSD), acute stress disorder, or adjustment disorders). Procedure. The dataset comprised a cohort of Medicaid eligible children, ages birth to 15-years during baseline years 1996-2001 and followed at least I year until age 19 years or the end of 2003. Childhood cancer Survivors (N = 390) identified from the SC Central Cancer Registry were frequency matched within age groups at each baseline year to children with no history of malignancy (N = 1,329). Survival curves and cumulative incidence of SRMD were estimated using the Kaplan-Meier method. Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for pediatric cancer survival and selected covariates. Results. The 8-year incidence of SRMD was 18.6% (95% CI: 12.47, 24.8) among childhood cancer survivors and 7.3% (5.0, 9.6) among children with no history of malignancy, HR=3.22 (2.17, 4.76). Significant covariates for this group included race, sex, and previous mental disorder, adjusted HR=3.00 (2.02, 4.45). Significant predictors among the childhood cancer survivors included cancer type, age group, treatment, and previous mental disorder. Conclusions. Given the potential benefit of interventions for those with prior psychopathology, that children are less likely to verbalize emotional problems, and the detrimental implications of undiagnosed mental disorders, the health evaluations of childhood cancer patients and the follow-up visits for the survivors should incorporate assessment for mental disorders, especially SRMD.

BACKGROUND. Although patients who have early-stage oropharyngeal cancer can be treated with little impairment of function, the treatment of advanced disease can result in decreased quality of life and mortality. Patients without insurance and with other barriers to access to care may delay seeking medical attention for early symptoms, resulting in more advanced disease at presentation. In this study, the authors examined whether patients who had no insurance or who were covered by Medicaid insurance were more likely to present with advanced oropharyngeal cancer.METHODS. In this retrospective cohort study from the National Cancer Database from 1996 to 2003, patients with known insurance status who were diagnosed with invasive oropharyngeal cancer at Commission on Cancer facilities (n = 40,487) were included. Adjusted and unadjusted logistic regression models were used to analyze the likelihood of presenting with more advanced stage disease.RESULTS. After controlling for other so cio demographic characteristics, patients with advanced oropharyngeal cancer at diagnosis were more likely to be uninsured (odds ratio [OR], 1.37; 95% confidence interval [95% CI], 1.21-1.25) or covered by Medicaid (OR, 1.31; 95% CI, 1.19-1.46) compared with patients who had private insurance. Similarly, patients were most likely to present with the largest tumors (T4 disease) if they were uninsured (OR, 2.82; 95% CI, 2.46-3.23) or covered by Medicaid (OR, 2.95; 95% CI, 2.63-3.31). They also were more likely to present with the greatest degree of lymph node involvement (N3) if they were uninsured (OR, 2.06; 95% CI, 1.76-2.40) or covered by Medicaid (OR, 1.66; 95% Cl, 1.45-1.90).CONCLUSIONS. Individuals who lacked insurance or had Medicaid coverage were at the greatest risk for presenting with advanced oropharyngeal cancer. In the current study, the results for the Medicaid group may have been influenced by the postdiagnostic enrollment of uninsured patients. Insurance coverage appeared to be a highly modifiable predictor of cancer stage. The findings indicated that it is important to consider the impact of insurance coverage on disease stage at diagnosis and associated morbidity, mortality, and quality of life.

Advances in the prevention, early detection, and treatment of cancer have resulted in an almost 14% decrease in the death rates from all cancers combined from 1991 to 2004 in the overall US population, with remarkable declines in mortality for the top 3 causes of cancer death in men (lung, colorectal, and prostate cancer) and 2 of the top 3 cancers in women (breast and colorectal cancer). However, not all segments of the population have benefited equally from this progress, and evidence suggests that some of these differences are related to lack of access to health care. Lack of adequate health insurance appears to be a critical barrier to receipt of appropriate health care services. This article provides an overview of systems of health insurance in the United States, demographic and socioeconomic characteristics associated with health insurance coverage, and economic burdens related to health care among individuals and families. This article also presents data on the association between health insurance status and screening, stage at diagnosis, and survival for breast and colorectal cancer based on analyses of the National Health Interview Survey and the National Cancer Data Base. Although this article focuses on associations between health insurance and cancer care utilization and outcomes, it is important to recognize that barriers to receipt of optimal cancer care are complex and involve patient-level, provider, and health system factors. Evidence presented in this paper suggests that addressing insurance and cost-related barriers to care is a critical component of efforts to ensure that all Americans are able to share in the progress that can be achieved by access to high-quality cancer prevention, early detection, and treatment services.

BACKGROUND. individuals without medical insurance or with limited insurance are less likely than those with broader insurance coverage to receive preventive services and to seek timely medical care. The authors examined the associations of insurance status with stage at diagnosis among women with breast cancer.METHODS. This study included women age >= 40 years who were diagnosed with invasive breast cancer from 1998 to 2003 and who were reported to the National Cancer Data Base. Multivariable logistic regression analyses were used to examine the associations of insurance status with more advanced-stage breast cancer at diagnosis while controlling for other patient characteristics.RESULTS. Among the 533,715 women with breast cancer who were included in the current analysis, the proportions with advanced-stage (III/IV) cancer at diagnosis ranged from 8% among privately insured patients to 18% among uninsured patients and 19% among Medicaid patients; differences in the proportions of women with advanced-stage cancer were statistically significant (P <.0001). Regression analyses indicated that, compared with privately insured patients, uninsured patients and Medicaid patients had a greater likelihood of diagnosis at stage 11 (odds ratio [OR], -1.5) or at stages III/IV (OR, 2.4) versus stage I (P <.001). Black and Hispanic patients also were significantly more likely than white patients to be diagnosed at a more advanced stage (P <.001).CONCLUSIONS. The results from this study provided strong evidence that patients without health insurance or with Medicaid coverage, as well as black and Hispanic patients, were more likely to present with advanced-stage breast cancer. These results are consistent with other reports that have documented less use of preventive services, including mammography, among uninsured women and delays in diagnosis and treatment for black and Hispanic women.

Objective. The aim of this study is to describe patterns of care of advanced oropharyngeal cancer during 1985 to 2001. Methods. We extracted oropharyngeal squamous cell cancer cases from the National Cancer Database. Type of initial treatment, type of facility, stage of tumor, payer status, and demographic variables were collected. Fisher exact test was used to compare the patient demographic and clinical characteristics across facility types. Weighted least squares regression analysis was used to analyze treatment trends over time and t-tests were done to test for significance in trends. Results: A total of 54,801 cases were available for analysis. Teaching/research facilities treated a disproportionately higher number of advanced-stage cancers (81%, P <.01). In addition, these facilities treat a higher percentage of uninsured (7%, P <.01) and nonwhite patients (27%, P <.01). The use of organ preservation protocols (chemoradiation) increased from 15% in 1985 to 29% in 2001 (beta(1) = 0.0080, P <.05), whereas the use of radiation alone decreased from 42% in 1985 to 27% in 2001 (beta(1) = -0.0118, P <.05). The use of cancer-directed surgery remained stable. There was no difference in rates of chemoradiation for advanced oropharyngeal cancer across facility types. Conclusions: Our results suggest that chemoradiation is increasingly becoming more prevalent at all facility types. The use of radiation alone as primary treatment significantly declined during the study period. In view of the complexity and multidisciplinary nature of treatment for oropharyngeal cancer, it is recommended that care of such patients be discussed at institutional tumor boards and that the recommendations be systematically recorded and documented in hospital cancer registries.

OBJECTIVE To examine whether patients with no insurance or Medicaid are more likely to present with advanced-stage laryngeal cancer. DESIGN Retrospective cohort study from the National Cancer Database, 1996-2003. SETTING Hospital-based practice. PARTICIPANTS Patients with known insurance status diagnosed as having invasive laryngeal cancer at Commission on Cancer facilities (N = 61 131) were included. Adjusted and unadjusted logistic regression models analyzed the likelihood of presenting at a more advanced stage. MAIN OUTCOME MEASURES Overall stage of laryngeal cancer (early vs advanced) and tumor size (T stage) at diagnosis. RESULTS Patients with advanced-stage laryngeal cancer at diagnosis were more likely to be uninsured (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.79-2.15) or covered by Medicaid (OR, 2.40; 95% CI, 2.21-2.61) compared with those with private insurance. Similarly, patients were most likely to present with the largest tumors (T4 disease) if they were uninsured (OR, 2.92; 95% CI, 2.60-3.28) or covered by Medicaid (OR, 3.97; 95% CI, 3.56-4.34). Patients who were black, between ages 18 and 56 years, and who resided in zip codes with low proportions of high school graduates or low median household incomes were also more likely to be diagnosed as having advanced disease and/or larger tumors. CONCLUSIONS Individuals lacking insurance or having Medicaid are at greatest risk for presenting with advanced laryngeal cancer. Results for the Medicaid group may be influenced by the postdiagnosis enrollment of uninsured patients. It is important to consider the impact of insurance coverage on stage at diagnosis and associated morbidity, mortality, quality of life, and costs.

OBJECTIVE:In 1991, a randomized study was published and demonstrated that use of nonsurgical therapy (chemoradiation) provided similar survival to total laryngectomy (the gold standard) for patients with advanced-stage laryngeal cancer. The purpose of this study was to assess how treatment of advanced laryngeal cancer was influenced by such developments in non-surgical therapy. STUDY DESIGN:Patterns of care study using National Cancer Database (1985-2001). RESULTS:The percentage of advanced-stage patients treated with chemoradiation increased from 8.3% to 20.8% while the proportion treated with radiation alone decreased from 38.9% to 23.0%. Use of chemoradiation increased at a significantly faster rate after the 1991 publication at both community cancer centers and teaching research facilities. The use of total laryngectomy decreased slightly during this period. CONCLUSIONS:The use of chemoradiation increased after the 1991 publication. It was impossible to determine from the NCDB whether additional patients who could benefit from chemo-RT were not offered or did not complete this treatment option. We recommend that treatment recommendations discussed at tumor boards be recorded in cancer registries.