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People without health insurance and those on Medicaid are more likely to be diagnosed with advanced stages of cancer than those with private health insurance, American Cancer Society researchers report. The findings, published in 2 studies in the journal Cancer, highlight the dramatic impact insurance status has on people's health and well-being, the researchers say.

"It's a very consistent picture in terms of being uninsured or underinsured having a significant effect on advanced disease -- it's not just that it appears in one type of cancer and no place else," says Michael T. Halpern, MD, PhD, strategic director of health services at the American Cancer Society and coauthor of the 2 reports.

Halpern and his colleagues used the National Cancer Data Base to compare stage at diagnosis and insurance status in nearly 534,000 breast cancer patients between 1998 and 2003, and in more than 40,000 men and women diagnosed with oropharyngeal cancer (cancer in the mouth or throat) between 1996 and 2003. The team is conducting similar analyses on several other types of cancer, as well.

The oral cancer analysis, the first of its kind, found that patients who were uninsured or on Medicaid were significantly more likely to be diagnosed with more advanced (stage III or IV) cancers compared to people with private insurance. They were more likely to present with larger tumors and with tumors that had spread to the lymph nodes.

The breast cancer analysis showed that just 8% of women with private insurance had stage III or IV breast cancer at diagnosis, compared to 18% of uninsured women and 19% of women on Medicaid. Advanced stage disease was also more commonly diagnosed in African-American and Hispanic women compared to white women.

More advanced tumors are harder to treat successfully, and patients often face harsher side effects from that treatment, Halpern notes.

Although smaller scale studies also have shown more advanced breast cancer diagnoses among uninsured and underinsured women, Halpern says the magnitude of the difference was surprising, particularly for Medicaid coverage.

Some of the Medicaid gap may have been caused when uninsured people with advanced cancer were transferred to Medicaid as a result of their diagnosis, Halpern says. But that can't account for the entire difference. Most likely, inadequate coverage under Medicaid also played a role.

"Even when you have insurance, there's going to be tremendous variety in terms of deductibles, co-payments, and access to care, so even having insurance isn't a guarantee of access to timely and adequate care, and the findings for Medicaid point to this," he notes.

That point is crucial in the ongoing debate about reforming the US healthcare system, according to an editorial accompanying the studies.

"An exclusive focus on the uninsured, although it may be fundamental, is not sufficient," writes Richard C. Wender, MD, president of the American Cancer Society and chair of the department of family medicine at Thomas Jefferson University. "Adequacy of coverage and availability of appropriate health care services are equally vital."

For instance, previous studies have shown that preventive care like mammography often falls by the wayside when insurance coverage is inadequate; women without insurance are less likely to get these important screening tests than women who are covered.

Indeed, a recent study from the National Cancer Institute cited lack of insurance and higher co-pays as possible contributing factors behind the 4% decline in US mammography rates from 2000-2005.

"I don't think the study we did can directly shed light on why rates of mammography are going down," Halpern says, "but it does support [the] hypothesis that insurance plays a big role in terms of preventive care services, particularly mammography, and there are serious consequences to being uninsured and not getting those preventive services."

Affordable access to primary care doctors and preventive services like cancer screening are central to adequate coverage, Wender stresses.

"Individuals who have a regular source of primary care are both more likely to be up to date with cancer screening and more likely to receive timely follow-up and evaluation for abnormal findings," he writes.

Citations: "Insurance Status and Stage of Cancer at Diagnosis among Women with Breast Cancer." Published online June 11, 2007, in Cancer. First author: Michael Halpern, MD, PhD, American Cancer Society.

"The Impact of Health Insurance Status on Stage at Diagnosis of Oropharyngeal Cancer." Published online June 11, 2007, in Cancer. First author: Amy Y. Chen, MD, MPH, FACS, American Cancer Society.

"The Adequacy of the Access-to-Care Debate: Looking Through the Cancer Lens." Published online June 11, 2007, in Cancer. Author: Richard C. Wender, American Cancer Society and Thomas Jefferson University.