1. Hannah K Weir, PhD Epidemiology and Applied Research Branch North American Association of Central Cancer Registries Quebec City, Quebec, Canada June 2010 Cancer Survival According to Insurance Status in Kentucky National Center for Chronic Disease Prevention and Health Promotion Division of Cancer Prevention and Control

2. Co-Authors Thomas C Tucker, Kentucky Cancer Registry, Lexington, Kentucky, USA Claudia Allemani, National Cancer Institute, Milan, Italy Bernard Rachet, London School of Hygiene and Tropical Medicine (LSHTM), London, UK Michel P Coleman, LSHTM, London, UK

3. Institute of Medicine Ensuring Quality Cancer Care “ We all want to believe that when people get cancer, they will receive medical care of the highest quality. Even as new scientific breakthroughs are announced, though, many cancer patients may be getting the wrong care, too little care, or too much care, in the form of unnecessary procedures.” (IOM I999)

4. Avoidable Deaths “…equal treatment yields equal outcome among patients with the same stage of disease regardless of race,…” Brawley OW, Freeman HP. Race and outcomes: is this the end of the beginning for minority health research? J Natl Cancer Inst 1999; 91: 1908-9 “…. geography or socio-economic status”. Rachet B, Woods LM, Mitry E, Riga M, Cooper C, Quinn MJ, Steward JA, Brenner H, Estève J, Sullivan R, Coleman MP. Cancer survival in England and Wales at the end of the 20th century. Br J Cancer 2008; 99 (Suppl. 1): 2-10

5. What survival can tell us Clinical trials - highest achievable survival Population - overall survival achieved Coleman MP. Opinion: why the variation in breast cancer survival in Europe? Breast Cancer Res 1999, 1:22-24

6. Cancer Survival in Kentucky and Health Insurance Coverage (McDavid et al. 2003) 3-year relative survival for cancer patients diagnosed with female breast, colorectal, prostate and lung cancers between 1995-1998 varied by insurance type

7. Objective of this study To update and extend the previous study to include Kentucky women diagnosed with cervical cancer, and to examine the impact of insurance type, race and SES on cancer survival estimated from individual patient data

8. Methods and Materials KY residents (15-99 years), diagnosed with invasive breast (female), colorectal, lung, prostate cancer or cervical cancer during 1995-2006 and followed through 2007 Constructed age-, sex-, race-, calendar year- and SES-specific life tables to adjust for background mortality. – SES: quintiles based on 200% below poverty and extracted from the county attributes file available from SEER and linked to the life-table through the variable county. Estimated 1- and 3- year relative survival (RS) by insurance type using the cohort approach.

9. Private:managed care, HMO, PPO, private insurance Medicare:without supplement, including administered managed Care Medicare Plus: Medicare with supplement, private supplement or with MEDICAID Federal:TRICARE, Military, Veterans affairs, Indian/Public Health Service Medicaid: including administered managed Care Insurance NOS: insured, not otherwise specified Uninsured:not insured and including self pay Unknown: insurance status unknown Health Insurance Categories

10. Case Counts by Health Insurance Breast (N=29,144) Private 5811 20% Medicare 3029 10 % Medicare Plus 8645 30% Federal 229 1% Medicaid 1483 5% Ins, NOS 7144 25% Uninsured 1022 4% Unknown 1781 6% Colorectal (N=24,359) Private 2961 12% Medicare 4026 17% Medicare Plus 10313 42% Federally 524 2% Medicaid 909 4% Ins, NOS 3481 14% Uninsured 664 3% Unknown 1481 6%

11. One- and 3-year relative survival (%) by health insurance: Breast cancer, women diagnosed 2003-2006, FU 2007

12. Trends in Breast Cancer 3-year RS by Health Insurance

13. One- and 3-year relative survival (%) by health insurance: Colorectal, patients diagnosed 2003-2006, FU 2007

14. Trends in Colorectal Cancer 3-year RS By Health Insurance

15. Conclusion 3-year RS for breast and colorectal cancer varied by health insurance Highest for private and insured NOS Lowest for Medicaid, uninsured and insurance status unknown Survival for breast and colorectal cancer improved between 1995 and 2006 for private and insurance NOS

16. Limitations Those with unspecified insurance (NOS) accounted for a large number of cases Health insurance may represent insurance status at initial presentation or at discharge (e.g., Medicare) Analyses not currently adjusted for age, stage or treatment

17. Future Direction Analyses to include additional cancers The relationship between relative survival and insurance type, SES, race, stage at diagnosis, gender and treatment will be examined with multi-variable excess hazard models

18. For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Thank You Hannah K Weir 770 488-3006 hbw4@cdc.gov hbw4@cdc.gov National Center for Chronic Disease Prevention and Health Promotion Division of Cancer Prevention and Control