In the past several years, we have witnessed advances and innovations in the prevention and treatment of breast cancer, which have resulted in decreased mortality from the disease, as well as dramatic improvements in the quality of life of breast cancer survivors. Nonetheless, a persistent socioeconomic gradient is observed in the U.S. Consequently, certain groups of patients experience far less benefit from the improvements in prevention, diagnosis, and treatment of breast cancer. Patients with lower household incomes and uninsured patients have worse clinical outcomes in comparison with patients in higher socioeconomic brackets.
Even a cursory analysis of the National Cancer Database (NCDB) Public Benchmark Reports reveals that stage of diagnosis, use of breast conserving surgery, and administration of systemic therapy all vary on the basis of socioeconomic factors. The NCDB Public Benchmark Reports include the 14 most commonly diagnosed solid tumors in the U.S. and provide access to data from six diagnosis years (2003–2014), slightly more than 9 million cases. As of 2014 (the most recent year available for analysis in the NCDB Public Benchmark Reports), only 16.6 percent of patients without insurance presented at the earliest stage of breast cancer (stage 0; DCIS), versus 23.4 percent of patients with private insurance or managed care (p<0.05). Similarly, 11.4 percent of patients without insurance presented with stage IV disease, versus only 3.1 percent of patients with private insurance or managed care (p<0.05). Breast conserving surgery was performed in 52.6 percent of patients with private insurance/managed care, versus only 40.3 percent in patients without insurance (p<0.05). Perhaps of most concern, patients without insurance were less likely to receive systemic therapy for stage III to IV breast cancer in contrast to same-stage patients with private insurance or managed care (33.2 percent versus 15.5 percent, p<0.05).
Comparable trends in many of these inequalities are also observed with respect to household income (<$36,000 versus >$69,000), demonstrating a higher stage of presentation and less guideline concordant adjuvant therapy among patients with lower household incomes. Incidentally, data on many other common types of cancer reported in the NCDB display a similar socioeconomic pattern.
The full etiology of this observed financial disparity in breast cancer care is complex and multifactorial. However, one identified factor for this phenomenon is the barrier to appropriate preventative and therapeutic care faced by individuals with fewer economic resources. Studies have demonstrated that people with limited or no access to health care are less likely to receive appropriate cancer preventative services and standard-of-care therapy. Patients in the lowest income brackets are less likely to be insured, receive early intervention for disease, and complete recommended treatments.1-6 As a result, entire segments of the U.S. population are at higher risk of dying from breast cancer simply based on how much money they make and where they fall on the spectrum of insurance coverage.
The financial burden of cancer care has been recognized as a leading cause of personal bankruptcy.7-8 Furthermore, the cost to the health care system of caring for more advanced breast cancer is considerably higher than the cost of treating early-stage disease. This situation has important implications for a system struggling to control increasing costs, which threaten to reach unsustainable levels. Late-stage presentation of disease also is associated with a greater loss of productivity and premature death, which negatively affects the entire population.9-11
Addressing the care gap
Health care inequity has been evident in the U.S. for decades and reflects deeper issues in resource distribution, economic hierarchies, and social injustice. Inequality in health outcomes can be attributed to disparities in health, treatment, and the financial means to pay for the care needed to get and stay well. However, it is important to recognize that disparities in access to treatment are preventable. Failing to address the issues of access to appropriate cancer care and the health disparities that persist across socioeconomic and demographic lines is ethically intolerable.
Oncologists have had a long professional tradition rooted in the ideals of equality, compassion, and altruism, which may be why disparities in the health care of patients with cancer are so fundamentally unacceptable. Addressing these issues will require a systematic, dedicated, and multipronged approach that includes education reform, social equality, strengthened communities, and environmental protections. However, ensuring the provision of health care is another key strategy for overcoming the economic health gradient and narrowing the gaps in clinical outcomes.
In 1993, the New England Journal of Medicine published the results of a study evaluating the relationship between health insurance coverage and clinical outcomes in 4,675 women with breast cancer.12 The study showed that uninsured and underinsured patients presented with more advanced disease and experienced worse survival rates. The authors concluded that women would benefit from improved access to screening and optimal breast cancer therapy.12 Similarly, in 2010, a study of 843,177 patients using NCDB data indicated that women who lack adequate insurance had the highest proportion of stage III and IV disease when compared with women who had private insurance and Medicare plus supplemental insurance. The study concluded that extending insurance coverage would likely result in a decrease in late-stage cancer presentation.13
Impact of health reform
Prior to the passage of the Affordable Care Act (ACA) of 2010, many women seeking breast care encountered challenges with securing health insurance coverage, especially women at high risk for breast cancer or with a prior history of disease. Policies often excluded people with preexisting conditions, charged higher premiums for people with health risks, increased fees for young women, limited annual and lifetime benefits, or were nonrenewable for individuals who developed disease.14 As a result, some policies only were available to healthy or high-income populations.
The ACA was an important first step toward narrowing the gap in health insurance coverage and, thereby, improving access to care. The ACA included provisions for access to appropriate breast cancer screening, as well as genetic counseling and testing when applicable. The legislation also stipulated rules preventing coverage limits and denials for preexisting conditions. These measures helped women overcome certain financial barriers to obtaining adequate breast care. Although not without its challenges, the ACA allowed many women to acquire health insurance and obtain access to care that they otherwise could not have afforded. Improved access to breast care has had a meaningful effect on stage of cancer diagnosis overall.14-16 Without safeguards like the preventative services provision of the ACA, many women could not afford the care they need for the prevention, early detection, and treatment of breast cancer. The principles of value-based health care include performance, accountability, sustainability, and outcomes for all patients. Eliminating financial barriers to health care is an important component of this goal.
Redesigning the health system has been recognized as a priority to improve quality and achieve value in health care. In fact, the value-based approach to health care quality improvement has immediate implications for reducing inequalities in breast cancer care and improving outcomes. Unfortunately, the burden of cancer is often greater for the poor and underinsured patient population. Issues stem from limited access, lack of resources, marginalization, and social indifference.
Ideally, our nation’s health care system would guarantee that all breast cancer patients could access appropriate care and would receive this care in a timely fashion. This change begins with improving awareness of the existing deficiencies in our nation’s health care system and adopting the social will to truly transform care. Just as evidence-based medicine has improved clinical decision making in patient care, evidence-based policy should be used to inform decisions about health care reform in order to create a system that will benefit the entire population. The evidence indicates that eliminating financial barriers and improving access to care will improve the health of individuals with or at risk for breast cancer. Ultimately, with all of us working together, we can make a difference for our patients.
- Sprague BL, Trentham-Dietz A, Gangnon RE, et al. Socioeconomic status and survival after an invasive breast cancer diagnosis. Cancer. 2011;117(7):1542-1551.
- Feinglass J, Rydzewski N, Yang A. The socioeconomic gradient in all-cause mortality for women with breast cancer: Findings from the 1998 to 2006 National Cancer Data Base with follow-up through 2011. Ann Epidemiol. 2015;25(8):549-555.
- Byers TE, Wolf HJ, Bauer KR, et al. The impact of socioeconomic status on survival after cancer in the United States: Findings from the National Program of Cancer Registries Patterns of Care Study. Cancer. 2008;113(3):582-591.
- Cross CK, Harris J, Recht A. Race, socioeconomic status, and breast carcinoma in the U.S: What have we learned from clinical studies. Cancer. 2002;95(9):1988-1999.
- Coburn N, Fulton J, Pearlman DN, Law C, DiPaolo B, Cady B. Treatment variation by insurance status for breast cancer patients. Breast J. 2008;14(2):128-134.
- Amini A, Jones BL, Yeh N, et al. Disparities in disease presentation in the four screenable cancers according to health insurance status. Public Health. 2016;138:50-56.
- Yabroff KR, Lund J, Kepka D, Mariotto A. Economic burden of cancer in the United States: Estimates, projections, and future research. Cancer Epidemiol Biomarkers Prev. 2011;20(10):2006-2014.
- Fenn KM, Evans SB, McCorkle R, et al. Impact of financial burden of cancer on survivors’ quality of life. J Oncol Pract. 2014;10(5):332-338.
- Blumen H, Fitch K, Polkus V. Comparison of treatment costs for breast cancer, by tumor stage and type of service. Am Health Drug Benefits. 2016;9(1):23-32.
- Berkowitz N, Gupta S, Silberman G. Estimates of the lifetime direct costs of treatment for metastatic breast cancer. Value Health. 2000;3(1):23-30.
- Campbell JD, Ramsey SD. The costs of treating breast cancer in the U.S.: A synthesis of published evidence. Pharmacoeconomics. 2009;27(3):199-209.
- 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(5):326-331.
- Ward EM, Fedewa SA, Cokkinides V, Virgo K. The association of insurance and stage at diagnosis among patients aged 55 to 74 years in the national cancer database. Cancer J. 2010;16(6):614-621.
- Blumenthal D, Collins S. Where both the ACA and AHCA fall short, and what the health insurance market really needs. Harvard Business Review. March 21, 2017. Available at: https://hbr.org/2017/03/where-both-the-aca-and-ahca-fall-short-and-what-the-health-insurance-market-really-needs. Accessed August 21, 2017.
- Han X, Zhu S, Tian Y, Kohler BA, Jemal A, Ward EJ. Insurance status and cancer stage at diagnosis prior to the Affordable Care Act in the United States. J Registry Manag. 2016;41(3):143-151.
- Silva A, Molina Y, Hunt B, Markossian T, Saiyed N. Potential impact of the Affordable Care Act’s preventive services provision on breast cancer stage: A preliminary assessment. Cancer Epidemiol. June 9, 2017 [Epub ahead of print].