Association of Insurance Status and Racial Disparities With the Detection of Early-Stage Breast Cancer
Association of Insurance Status and Racial Disparities With the Detection of Early-Stage Breast Cancer
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DOI：
10.1001/jamaoncol.2019.5672
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发表时间：
2020-03-01
期刊：
影响因子：
28.4
通讯作者：
Calip, Gregory S.
中科院分区：
文献类型：
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作者：
Ko, Naomi Y.;Hong, Susan;Calip, Gregory S.
重要性与非西班牙裔白色女性相比，少数种族/族裔女性在更晚期接受乳腺癌诊断，并且乳腺癌诊断的发病率和死亡率更高。获得适当保险的护理可能与早期诊断，加速治疗和改善预后有关。目的研究保险与获得及时的乳腺癌诊断和乳腺癌分期之间的差异在多大程度上与大量不同的美国乳腺癌患者人群相关。设计、设置和参与者这项回顾性、横断面、基于人群的研究使用了来自监测、流行病学和最终结果项目的数据，研究对象为177075名年龄在40至64岁之间的女性，她们在2010年1月1日至2016年12月31日期间被诊断为I至III期乳腺癌。从2017年8月1日至2019年10月1日进行统计分析。主要结局和测量主要结局是诊断时乳腺癌更晚期的风险（即III期vs I期和II期）。进行中介分析，以确定种族/民族的关联和比例的观察到的差异介导的健康保险状态与早期诊断。结果共有177075名妇女（平均[SD]年龄，53.5 [6.8]岁; 148124名投保人和28951名未投保或接受医疗补助）被纳入研究。与有健康保险的妇女相比，接受医疗补助或没有保险的妇女被诊断为局部晚期乳腺癌（III期）的比例更高（20%比11%）。在多变量模型中，非西班牙裔黑人（比值比[OR]，1.46 [95% CI，1.40-1.53]），美洲印第安人或阿拉斯加原住民（OR，1.31 [95% CI，1.07-1.61]）和西班牙裔（OR，1.35 [95%CI，1.30-1.42]）与非西班牙裔白色女性相比，女性接受局部晚期疾病（III期）诊断的几率更高。当调整健康保险和其他社会经济因素时，种族/民族与局部晚期乳腺癌风险之间的关联减弱（非西班牙裔黑人：OR，1.29 [95% CI，1.23-1.35];美洲印第安人或阿拉斯加原住民：OR，1.11 [95% CI，0.91-1.35];西班牙裔：OR，1.17 [95% CI，1.12-1.22]）。近一半（45%-47%）的局部晚期疾病风险的种族差异是由健康保险介导的。结论和相关性这项研究的结果表明，近一半的观察到的种族/民族差异在较高阶段的乳腺癌诊断介导的健康保险覆盖范围。
Importance Compared with non-Hispanic white women, racial/ethnic minority women receive a diagnosis of breast cancer at a more advanced stage and have higher morbidity and mortality with breast cancer diagnosis. Access to care with adequate insurance may be associated with earlier diagnosis, expedited treatment, and improved prognosis. Objective To examine the extent to which insurance is associated with access to timely breast cancer diagnosis and breast cancer stage differences among a large, diverse population of US patients with breast cancer. Design, Setting, and Participants This retrospective, cross-sectional population-based study used data from the Surveillance, Epidemiology, and End Results Program on 177 075 women aged 40 to 64 years who received a diagnosis of stage I to III breast cancer between January 1, 2010, and December 31, 2016. Statistical analysis was performed from August 1, 2017, to October 1, 2019. Main Outcomes and Measures The primary outcome was the risk of having a more advanced stage of breast cancer at diagnosis (ie, stage III vs stages I and II). Mediation analyses were conducted to determine associations of race/ethnicity and proportion of observed differences mediated by health insurance status with earlier stage of diagnosis. Results A total of 177 075 women (mean [SD] age, 53.5 [6.8] years; 148 124 insured and 28 951 uninsured or receiving Medicaid) were included in the study. A higher proportion of women either receiving Medicaid or who were uninsured received a diagnosis of locally advanced breast cancer (stage III) compared with women with health insurance (20% vs 11%). In multivariable models, non-Hispanic black (odds ratio [OR], 1.46 [95% CI, 1.40-1.53]), American Indian or Alaskan Native (OR, 1.31 [95% CI, 1.07-1.61]) and Hispanic (OR, 1.35 [95% CI, 1.30-1.42]) women had higher odds of receiving a diagnosis of locally advanced disease (stage III) compared with non-Hispanic white women. When adjusting for health insurance and other socioeconomic factors, associations between race/ethnicity and risk of locally advanced breast cancer were attenuated (non-Hispanic black: OR, 1.29 [95% CI, 1.23-1.35]; American Indian or Alaskan Native: OR, 1.11 [95% CI, 0.91-1.35]; Hispanic: OR, 1.17 [95% CI, 1.12-1.22]). Nearly half (45%-47%) of racial differences in the risk of locally advanced disease were mediated by health insurance. Conclusions and Relevance This study's findings suggest that nearly half of the observed racial/ethnic disparities in higher stage at breast cancer diagnosis are mediated by health insurance coverage.