An article published this week in the medical journal Cancer Epidemiology, Biomarkers and Prevention and written by my colleagues at the American Cancer Society sends me a message that we can run but we can't hide.
The topic of the research is the relationship between whether or not a man has adequate (or any) health insurance and how far advanced and aggressive his prostate cancer is at the time of diagnosis.
The message we seem to be running from is that we continue to bury our heads in the sand at the sad truth that people without adequate health insurance are somehow less worthy of having some decent level of medical care that might save their lives, especially when viewed through the cancer lense.
Perhaps it was no surprise that the researchers found that there was a direct relationship between insurance coverage and measures of the aggressiveness of prostate cancer: the less insurance coverage (or no insurance coverage), the more likely it was that the man had more advanced and more aggressive disease.
This is a message there that is consistent with what we have seen before in similar studies about cancer diagnoses and insurance: the better the insurance coverage, the more likely you are to have your cancer found at an earlier stage. When you consider that message through the experience of the cancer patient, it puts our current nationwide discussion about health insurance reform into a much different perspective than what we are becoming accustomed to hearing these days.
Let's discuss the study itself, because it is truly remarkable when you consider how many patients the researchers were able to follow.
The records of a little over 312,000 men newly diagnosed with prostate cancer between 2004 and 2006 were examined for this study. The records were obtained through the National Cancer Database, a cooperative effort funded in large part by the American Cancer Society and the American College of Surgeons.
This database monitors the cancer status of patients diagnosed at over 1500 hospitals throughout the United States that participate in the Commission on Cancer which in turn is managed by the American College of Surgeons. What is unique about this database is that it includes ethnic and insurance status, unlike other nationwide efforts to accumulate similar information.
The researchers studied a number of factors that were of interest in determining the impact of insurance status on how advanced the prostate cancers were at the time of diagnosis. These included features of the cancer such as the size of the cancer, the Gleason score (which is measure of how aggressive the cancer looks under the microscope when examined by the pathologist), and the PSA level at the time of diagnosis.
They also determined how old the man was at the time of diagnosis (from ages 18-99), what type of insurance they had (including-if they were on Medicare-whether they had no supplemental insurance, private insurance, Medicaid supplemental, Medicaid alone or no insurance), and a measure of educational status. They also determined how many other chronic illnesses the man had at the time of prostate cancer diagnosis.
When examining all of these factors, they found that insurance status played a major role in determining how advanced a man's prostate cancer was when he was diagnosed.
The "base" case for comparison was a white male, ages 65-69, with private insurance, no other medical illnesses and living in a high socioeconomic area.
If you compare that group with uninsured and Medicaid patients, PSA results in the latter group were on average about 4 ng/ml higher than the "base case" group, whose PSAs averaged 8.83 at diagnosis ("normal" PSA is 4 or less). Blacks had higher PSAs at diagnosis than whites, as did Asians and Hispanics (although theirs were lower than blacks).
Looking at insurance status, the poorer your insurance the more likely you were to have a higher PSA with uninsured patients having the highest PSA levels.
More aggressive cancers as measured by the Gleason score were found in increasingly older men. Here again, however, insurance also made a difference with those having the best coverage showing the lowest Gleason scores, and those with poor or no coverage having higher scores (recall that Gleason scores are a measure of the cancer's aggressiveness when examined under the microscope). However, when looking at men ages 65 and over-the vast majority of whom have at least Medicare coverage-it was the men who were uninsured or had just Medicaid who had the higher Gleason scores, compared to men with more typical Medicare/supplemental coverage where the Gleason scores showed no significant differences.
When looking at advanced stage of disease at diagnosis, men with no insurance, Medicaid only, and older men had higher chances of more advanced disease.
Another interesting and important finding of this study was that there was a difference in advanced disease status when comparing white men to other ethnic groups, with white men having less aggressive cancers overall.
However as the authors note, insurance status had more influence over advanced disease than did ethnicity. In addition, although black men had more advanced disease than white men, insurance status did temper that finding suggesting that access to care makes a difference in stage at diagnosis and ultimately on outcome. Once again, insurance "trumped" race in large part, suggesting that it is access to care that is the real culprit.
Given all of the discussion recently about whether or not PSA screening saves lives, what does this study really tell us?
First, and perhaps most important, having adequate health insurance does count when it comes to diagnosing and treating cancer effectively. No insurance or poor insurance coverage means more advanced prostate cancer at diagnosis. More advanced disease at diagnosis means a much, much higher chance of death from the disease. And this isn't true only for prostate cancer, but several other cancers where similar research has been done.
It's true that in our prostate cancer screening guidelines, the American Cancer Society advocates that men have a discussion with their health care professional about whether or not they should be screened for prostate cancer before they embark on a screening program with PSA tests. We don't know whether or not early diagnosis of prostate cancer saves lives, and we certainly don't object if men decide to get screened, so long as they know all the facts. But it is the discussion that it is important, and men without insurance or poor insurance are men who won't even have the opportunity to have that basic conversation and make a decision that is right for them.
The net result? Men without adequate health insurance don't have that conversation, and get diagnosed at later stages when looked at as a population in its entirety.
It's also important to remember that it is possible that men in this study who had Medicaid as their primary insurance coverage were in fact uninsured when they went to the doctor to get diagnosed. Frequently, these men are quickly put on Medicaid in order to be able to get the tests they need to make the diagnosis and end up in the "Medicaid" column in studies such as this, even though prior to that time they may have not had health insurance.
There is certainly a lot of heat around the wisdom of health insurance reform. But for the American Cancer Society, the fundamental question is how we deal with this issue through the lens of the cancer patient and the cancer experience.
What we have learned-what the science has shown us to be the fact-is that without health insurance you have few options. You can't go to the emergency room to get a diagnosis of prostate cancer, unless it is advanced and causing serious symptoms. You can't get to a doctor to talk about your options, because you frequently can't afford to go. Very simply, what you can't afford when you don't have adequate health insurance is routine medical care-let alone more expensive medical care.
So, what we seem to be saying when we talk about the need to help people have access to care through adequate health insurance coverage is that what you can afford is to get advanced cancer and possibly die from the disease.
That, my friends, is the message our science-not our opinion--is telling us. And that is something no civil society should be willing to afford.