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abstract
BACKGROUND
Individuals
from disadvantaged communities are among the millions of uninsured
Americans gaining insurance under the Affordable Care Act. The extent to
which health insurance can mitigate the effects of the social
determinants of health on cancer care is unknown.
METHODS
This
study linked the Surveillance, Epidemiology, and End Results registries
to US Census data to study patients diagnosed with the 4 leading causes
of cancer deaths between 2007 and 2011. A county-level social
determinant score was developed with 5 measures of wealth, education,
and employment. Patients were stratified into quintiles, with the lowest
quintile representing the most disadvantaged communities. Logistic
regression and Cox proportional hazards models were used to estimate
associations and cancer-specific survival.
RESULTS
A
total of 364,507 patients aged 18 to 64 years were identified (134,105
with breast cancer, 106,914 with prostate cancer, 62,606 with lung
cancer, and 60,882 with colorectal cancer). Overall, patients from the
most disadvantaged communities (median household income, $42,885;
patients below the poverty level, 22%; patients completing college, 17%)
were more likely to present with distant disease (odds ratio, 1.6; P < .001) and were less likely to receive cancer-directed surgery (odds ratio, 0.8; P < .001)
than the least disadvantaged communities (median income, $78,249;
patients below the poverty level, 9%; patients completing college, 42%).
The differences persisted across quintiles regardless of the insurance
status. The effect of having insurance on cancer-specific survival was
more pronounced in disadvantaged communities (relative benefit at 3
years, 40% vs 31%). However, it did not fully mitigate the effect of
social determinants on mortality (hazard ratio, 0.75 vs 0.68; P < .001).
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