Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Original Article
  • Published:

Clinical Research

The association between insurance status and prostate cancer outcomes: implications for the Affordable Care Act

Prostate Cancer and Prostatic Diseases volume 17, pages 273–279 (2014)Cite this article

Subjects

Abstract

Background:

The Affordable Care Act (ACA) aims to expand health insurance coverage to over 30 million previously uninsured Americans. To help evaluate the potential impact of the ACA on prostate cancer care, we examined the associations between insurance coverage and prostate cancer outcomes among men <65 years old who are not yet eligible for Medicare.

Methods:

The Surveillance, Epidemiology and End Results Program was used to identify 85 203 men aged <65 years diagnosed with prostate cancer from 2007 to 2010. Multivariable logistic regression modeled the association between insurance status and stage at presentation. Among men with high-risk disease, the associations between insurance status and receipt of definitive therapy, prostate cancer-specific mortality (PCSM) and all-cause mortality were determined using multivariable logistic, Fine and Gray competing-risks and Cox regression models, respectively.

Results:

Uninsured patients were more likely to be non-white and come from regions of rural residence, lower median household income and lower education level (P<0.001 for all cases). Insured men were less likely to present with metastatic disease (adjusted odds ratio (AOR) 0.23; 95% confidence interval (CI) 0.20–0.27; P<0.001). Among men with high-risk disease, insured men were more likely to receive definitive treatment (AOR 2.29; 95% CI 1.81–2.89; P<0.001), and had decreased PCSM (adjusted hazard ratio 0.56; 95% CI 0.31–0.98; P=0.04) and all-cause mortality (adjusted hazard ratio 0.60; 0.39–0.91; P=0.01).

Conclusions:

Insured men with prostate cancer are less likely to present with metastatic disease, more likely to be treated if they develop high-risk disease and are more likely to survive their cancer, suggesting that expanding health coverage under the ACA may significantly improve outcomes for men with prostate cancer who are not yet eligible for Medicare.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1

Similar content being viewed by others

References

  1. United States Census Bureau. Census 2000 Gateway. [online database] Available at http://www.census.gov/main/www/cen2000html. Accessed 27 December 2013.

  2. Patient Protection and Affordable Care Act. Pub. L. No. 111-148, 114 Stat. 119 (210).

  3. Sommers BD, Bindman AB . New physicians, the Affordable Care Act, and the changing practice of medicine. JAMA 2012; 307: 1697–1698.

    Article  CAS  Google Scholar 

  4. Ferris LW, Farber M, Guidi TU, Laffey WJ . Impact of health care reform on the cancer patient: a view from cancer executives. Cancer J 2010; 16: 600–605.

    Article  Google Scholar 

  5. Keegan KA, Penson DF . The Patient Protection and Affordable Care Act: the impact on urologic cancer care. Urol Oncol 2013; 31: 980–984.

    Article  Google Scholar 

  6. Albright HW, Moreno M, Feeley TW, Walter R, Samuels M, Pereira A et al. The implications of the 2010 Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act on cancer care delivery. Cancer 2011; 117: 1564–1574.

    Article  Google Scholar 

  7. Siegel R, Ma J, Zou Z, Jemal A . Cancer statistics, 2014. CA Cancer J Clin 2014; 64: 9–29.

    Article  Google Scholar 

  8. SEER Cancer Statistics Review, 1975-2010 National Cancer Institute: Bethesda, MDhttp://seer.cancer.gov/csr/1975_2010/based on November 2012 SEER data submission, posted to the SEER website 2013.

  9. Surveillance, Epidemiology, and End Results (SEER) Program. Research Data (1973-2010), National Cancer Institute, DCCPS, Surveillance Research Program, Surveillance Systems Branch, based on November 2012 SEER data submission, posted to the SEER website 2013. www.seer.cancer.gov.

  10. NCCN Clinical Practice Guidelines in Oncology. Prostate Cancer 2014. Available at http://www.nccn.org. Accessed 30 December 2013.

  11. United States Department of Agriculture Rural-Urban Continuum Codes. [online database] Available at http://www.ers.usda.gov/data-products/rural-urban-continuum-codes.aspx. Accessed 27 December 2013.

  12. Boorjian SA, Karnes RJ, Rangel LJ, Bergstralh EJ, Blute ML . Mayo Clinic validation of the D'amico risk group classification for predicting survival following radical prostatectomy. J Urol 2008; 179: 1354–1360.

    Article  Google Scholar 

  13. Cox DR . Regression models and life-tables. J R Stat Soc B 1972; 34: 187–220.

    Google Scholar 

  14. Fine J, Gray R . A proportional hazards model for the subdistribution of a competing risk. J Am Stat Assoc 1999; 94: 496–509.

    Article  Google Scholar 

  15. Shen JJ, Washington EL . Disparities in outcomes among patients with stroke associated with insurance status. Stroke 2007; 38: 1010–1016.

    Article  Google Scholar 

  16. Glueckert LN, Redden D, Thompson MA, Haque A, Gray SH, Locke J et al. What liver transplant outcomes can be expected in the uninsured who become insured via the Affordable Care Act? Am J Transplant 2013; 13: 1533–1540.

    Article  CAS  Google Scholar 

  17. Hasan O, Orav EJ, Hicks LS . Insurance status and hospital care for myocardial infarction, stroke, and pneumonia. J Hosp Med 2010; 5: 452–459.

    Article  Google Scholar 

  18. Shi L, Lebrun LA, Zhu J, Tsai J . Cancer screening among racial/ethnic and insurance groups in the United States: a comparison of disparities in 2000 and 2008. J Health Care Poor Underserved 2011; 22: 945–961.

    Article  Google Scholar 

  19. Ayanian JZ, Kohler BA, Abe T, Epstein AM . The relation between health insurance coverage and clinical outcomes among women with breast cancer. N Engl J Med 1993; 329: 326–331.

    Article  CAS  Google Scholar 

  20. Trinh QD, Schmitges J, Sun M, Sammon J, Shariat SF, Zorn K et al. Morbidity and mortality of radical prostatectomy differs by insurance status. Cancer 2012; 118: 1803–1810.

    Article  Google Scholar 

  21. Kelz RR, Gimotty PA, Polsky D, Norman S, Fraker D, DeMichele A . Morbidity and mortality of colorectal carcinoma surgery differs by insurance status. Cancer 2004; 101: 2187–2194.

    Article  Google Scholar 

  22. Brookfield KF, Cheung MC, Lucci J, Fleming LE, Koniaris LG . Disparities in survival among women with invasive cervical cancer: a problem of access to care. Cancer 2009; 115: 166–178.

    Article  Google Scholar 

  23. Dasenbrock HH, Wolinsky JP, Sciubba DM, Witham TF, Gokaslan ZL, Bydon A . The impact of insurance status on outcomes after surgery for spinal metastases. Cancer 2012; 118: 4833–4841.

    Article  Google Scholar 

  24. Fedewa SA, Etzioni R, Flanders WD, Jemal A, Ward EM . Association of insurance and race/ethnicity with disease severity among men diagnosed with prostate cancer, National Cancer Database 2004-2006. Cancer Epidemiol Biomarkers Prev 2010; 19: 2437–2444.

    Article  Google Scholar 

  25. Sadetsky N, Lubeck DP, Pasta DJ, Latini DM, DuChane J, Carroll PR . Insurance and quality of life in men with prostate cancer: data from the Cancer of the Prostate Strategic Urological Research Endeavor. BJU Int 2008; 101: 691–697.

    Article  Google Scholar 

  26. Gallina A, Karakiewicz P, Chunk FK, Briganti A, Graefen M, Montorsi F et al. Health-insurance status is a determinant of the stage at presentation and of cancer control in European men treated with radical prostatectomy for clinically localized prostate cancer. BJU Int 2007; 99: 1404–1408.

    Article  Google Scholar 

  27. Penson DF, Stoddard ML, Pasta DJ, Lubeck DP, Flanders SC, Litwin MS . The association between socioeconomic status, health insurance coverage, and quality of life in men with prostate cancer. J Clin Epidemiol 2001; 54: 350–358.

    Article  CAS  Google Scholar 

  28. Roetzheim RG, Pal N, Tennant C, Voti L, Ayanian JZ, Schwabe A et al. Effects of health insurance and race on early detection of cancer. J Natl Cancer Inst 1999; 91: 1409–1415.

    Article  CAS  Google Scholar 

  29. Niu X, Roche LM, Pawlish KS, Henry KA . Cancer survival disparities by health insurance status. Cancer Med 2013; 2: 403–411.

    Article  Google Scholar 

  30. Cooperberg MR, Lubeck DP, Meng MV, Mehta SS, Carroll PR . The changing face of low-risk prostate cancer: trends in clinical presentation and primary management. J Clin Oncol 2004; 22: 2141–2149.

    Article  Google Scholar 

  31. Miller DC, Litwin MS, Bergman J, Stepanian S, Connor SE, Kwan L et al. Prostate cancer severity among low income, uninsured men. J Urol 2009; 181: 579–583.

    Article  Google Scholar 

  32. Brown ER, Davidson PL, Yu H, Wyn R, Andersen RM, Becerra L et al. Effects of community factors on access to ambulatory care for lower-income adults in large urban communities. Inquiry 2004; 41: 39–56.

    Article  Google Scholar 

  33. Stein JA, Andersen RM, Gelberg L . The Behavioral Model for Vulnerable Populations: application to medical care use and outcomes for homeless people. Health Serv Res 2000; 34: 1273–1302.

    Google Scholar 

  34. Miller DC, Gelberg L, Kwan L, Stepanian S, Fink A, Andersen RM et al. Racial disparities in access to care for men in a public assistance program for men in a public assistance program for prostate cancer. J Community Health 2008; 33: 318–335.

    Article  Google Scholar 

  35. Andersen RM, Yu H, Wyn R, Davidson PL, Brown ER, Teleki S . Access to medical care for low-income persons: how do communities make a difference? Med Care Res Rev 2002; 59: 384–411.

    Article  Google Scholar 

  36. Underwood W, De Monner S, Ubel P, Fagerlin A, Sanda MG, Wei JT . Racial/ethnic disparities in the treatment of localized/regional prostate cancer. J Urol 2004; 171: 1504–1507.

    Article  Google Scholar 

  37. Presley CJ, Raldow AC, Cramer LD, Soulos PR, Long JB, Yu JB et al. A new approach to understanding racial disparities in prostate cancer treatment. J Geriatr Oncol 2013; 4: 1–8.

    Article  Google Scholar 

  38. Hamilton AS, Fleming ST, Wang D, Goodman M, Wu XC, Owen JB et al. Clinical and demographic factors associated with receipt of non guideline-concordant initial therapy for nonmetastatic prostate cancer. Am J Clin Oncol 2014; e-pub ahead of print (Accessed 1 February 2014).

  39. Stokes WA, Hendrix LH, Royce TJ, Allen IM, Godley PA, Wang AZ et al. Racial differences in time from prostate cancer diagnosis to treatment initiation: a population-based study. Cancer 2013; 119: 2486–2493.

    Article  Google Scholar 

  40. Tewari AK, Gold HT, Demers RY, Johnson CC, Yadav R, Wagner EH et al. Effect of socioeconomic factors on long-term mortality in men with clinically localized prostate cancer. Urology 2009; 73: 624–630.

    Article  Google Scholar 

  41. Mahal BA, Ziehr DR, Aizer AA, Hyatt AS, Sammon JD, Schmid M et al. The influence of insurance status on racial disparities in the treatment of African-American men with high-risk prostate cancer. Urol Oncol 2014; e-pub ahead of print (Accessed 1 May 2014).

  42. Steelfisher GK, Blendon RJ, Sussman T, Connolly JM, Benson JM, Herrmann MJ . Physicians’ views of the Massachusetts Health Care Reform Law—a poll. N Engl J Med 2009; 361: e39.

    Article  CAS  Google Scholar 

  43. Staiger DO, Auerbach DI, Buerhaus PI . Health care reform and the health care workforce—the Massachusetts experience. N Engl J Med 2011; 365: e24.

    Article  Google Scholar 

  44. Wilensky GR . The shortfalls of ‘Obamacare’. N Engl J Med 2012; 367: 1479–1481.

    Article  CAS  Google Scholar 

  45. Moyer VA . Screening for prostate cancer: U.S. Preventative Services Task Force recommendation statement. Ann Intern Med 2012; 157: 120–134.

    Article  Google Scholar 

Download references

Acknowledgements

This work is supported by David and Cynthia Chapin, the Prostate Cancer Foundation, Fitz’s Cancer Warriors, Hugh Simons in honor of Frank and Anne Simons and a grant from an anonymous family foundation.

Author information

Authors and Affiliations

  1. Harvard Medical School, Boston, MA, USA

    B A Mahal, D R Ziehr & C Lago-Hernandez

  2. Harvard Radiation Oncology Program, Boston, MA, USA

    A A Aizer

  3. Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    A S Hyatt, C J Beard, A V D'Amico, N E Martin & P L Nguyen

  4. Harvard School of Public Health, Boston, MA, USA

    Y-W Chen

  5. Department of Medical Oncology, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    T K Choueiri & C J Sweeney

  6. Department of Urology, UCLA Medical Center, Los Angeles, CA, USA

    J C Hu

  7. Division of Urology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Q-D Trinh

Authors
  1. B A Mahal
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. A A Aizer
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. D R Ziehr
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. A S Hyatt
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. C Lago-Hernandez
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Y-W Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. T K Choueiri
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. J C Hu
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. C J Sweeney
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. C J Beard
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. A V D'Amico
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. N E Martin
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Q-D Trinh
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. P L Nguyen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to P L Nguyen.

Ethics declarations

Competing interests

Paul L Nguyen consulted for Ferring and Medivation, and Quoc-Dien Trinh gave a paid lecture for Intuitive Surgical. The other authors declare no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Mahal, B., Aizer, A., Ziehr, D. et al. The association between insurance status and prostate cancer outcomes: implications for the Affordable Care Act. Prostate Cancer Prostatic Dis 17, 273–279 (2014). https://doi.org/10.1038/pcan.2014.23

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/pcan.2014.23

This article is cited by

Search

Advanced search

Quick links