1. Carlson, Robert H.

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SCOTTSDALE, ARIZ.-It's not unexpected news that evidence of serious healthcare disparities between the haves and have-nots continues to mount.

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A new study from the Fox Chase Cancer Center, Philadelphia, examining disparities among Medicaid and uninsured patients with head and neck cancer shows Medicaid patients are 23 percent less likely to undergo external beam radiotherapy, and the uninsured are 32 percent less likely.


Further, the uninsured were 14 percent less likely to receive cancer-directed therapy surgery.


The data were presented at the 2016 Multidisciplinary Head & Neck Cancer Symposium, sponsored by the American Society for Radiation Oncology (ASTRO) and the American Society of Clinical Oncology (ASCO).


As would be expected, these disparities have an impact on survival and stage of disease at presentation.

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"Uninsured and Medicaid patients with head and neck cancer are more likely to present with advanced tumors, have higher overall and cancer-specific mortality rates, and are less likely to undergo cancer-directed surgery or radiation therapy when compared with patients with non-Medicaid insurance," said Thomas M. Churilla, MD, a Resident Physician in Radiation Oncology at Fox Chase and lead author on the study. During an online audio preview of this meeting for the press, Churilla reported the following:


* The hazard ratio for overall mortality for Medicaid patients was 1.55 and 1.48 for uninsured patients, compared with insured patients.


* In cause-specific mortality, the hazard ratio was 1.60 for Medicaid patients and 1.64 for the uninsured, compared with insured patients.


* Seventy-five percent of uninsured patients and 73 percent of Medicaid patients presented with American Joint Committee on Cancer stage III or IV disease, compared with 60 percent of insured patients.



Senior study author is Thomas J. Galloway, MD, Assistant Professor and Director of Clinical Research, Department of Radiation Oncology at Fox Chase.


Churilla and colleagues drew on the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) database for clinical, demographic, and socioeconomic variables in the records of all 53,848 patients diagnosed with primary squamous cell carcinoma of the oral cavity, pharynx, or larynx between 2007 and 2012.


Patients were categorized as having non-Medicaid insurance (80.1 percent), Medicaid (15 percent), and patients who were uninsured (4.9 percent).


"We were surprised by the similarity in outcomes among the uninsured patients and Medicaid patients," Churilla said. "These findings suggest that other risk factors and barriers to care, in addition to health insurance coverage, are responsible for survival differences from head and neck cancers."


Not Likely to Change Practice

This study, while illuminating, is not likely to change practice, said the moderator of the online meeting preview, Randall Kimple, MD, Assistant Professor in the Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison.


In a telephone interview after the meeting, Kimple told OT he did not think this study has treatment implications "because frankly, the vast majority of oncologists take the best care of patients who come to them, regardless of what insurance those patients have."


And the study results would probably be no surprise to oncologists because, "intuitively, people believe that patients without insurance present later with more advanced disease and are likely have worse outcomes.


"What I think will be interesting is how the Affordable Care Act affects this," Kimple said. "Will we see fewer of these patients because more people have insurance?"


Kimple said that as the Affordable Care Act got underway, many practices around the country saw a relatively significant influx of new diagnoses of patients who hadn't been to the doctor in many years.


"Now they had insurance and they went to the doctor for an exam and were found to have cancer," he said.


This points to an important issue, Kimple said.


"In patients who have a new cancer diagnosis, if they then are provided with insurance, do their outcomes change compared with outcomes of patients who are uninsured all the way through the process?" Kimple said. "The data set in this study set is not able to give that detail, but that is an important question that has important policy implications."