Introduction and Objectives: Previous studies have demonstrated that for several cancers, uninsured and Medicaid-insured patients have poorer outcomes than those with private insurance. Those without private insurance may also have worse outcomes after prostate cancer treatment. We investigate the relationship between insurance status and prostate cancer outcomes in Oregon and explore potential reasons for this disparity.
Methods: Using the comprehensive, state-mandated, Oregon State Cancer Registry (OSCaR) we analyzed outcomes for men diagnosed with prostate cancer between 1996 and 2011. Health insurance status at the time of diagnosis was also determined. Prostate cancer stage, grade and PSA levels were compared according to insurance type, and prostate cancer-specific mortality was also assessed. For patients with localized disease, the distribution of treatment choice between radical prostatectomy and radiation therapy was determined according to health insurance status, and prostate cancer-specific survival after treatment was compared. Time from cancer diagnosis to each of treatment was also analyzed. Differences between health insurance groups were tested using t-test (or Wilcoxon test) and chi-square test. Prostate cancer (PCa)-specific mortality was estimated using competing risks survival analysis.
Results: Between 1996 and 2011, 37,156 men were diagnosed with prostate cancer and in 27,481, health insurance status was available. Of these, 47% had Medicare, 46% private insurance, 3.8% VA health care, 1.7% Medicaid and 1.4% were uninsured. Uninsured and Medicaid patients were much more likely than other insurance groups to present with very high risk disease (20.3% vs 8.7%, p<0.0001) and have high PSA values (percent with PSA > 10 ng/ml, 39% vs 24%, p<.0001). They also had a significantly higher risk of prostate cancer death compared with other insurance groups (7 year PCa-specific survival 68% versus 84%, respectively, p<0.0001). Medicaid and uninsured patients were more likely to choose radical prostatectomy than radiation therapy as primary treatment (47.1% vs 30.6%) compared to other insurance groups, but had similar times from diagnosis to primary treatment (mean 87 vs 88 days).
Conclusion: Prostate cancer outcomes in Oregon are strongly associated with insurance coverage status, with significantly worse cancers and higher cancer mortality observed in men who are without insurance or Medicaid-insured. This disparity in outcomes does not appear to be related to treatment selection or timing, suggesting that limited access to care and delayed diagnosis may in part contribute to these poor outcomes. While access to lower cost insurance may improve these outcomes, education on prostate cancer prevention, detection and treatment will also be important.