Associations of Health Insurance with Guideline-Concordant Treatment and Overall Survival Among Women with Breast Cancer.

Abstract

Purpose Inadequate health insurance is a barrier to timely, appropriate breast cancer treatment. This study examined the association of insurance with receipt of guideline-concordant therapy and overall survival. Methods Women aged ≥ 18 years when diagnosed with invasive breast cancer between 2014-2022 were identified through the California Cancer Registry (n = 200,080). Guideline-concordant treatment was defined by three Commission on Cancer quality measures: breast-conserving surgery (BCS) or mastectomy for American Joint Commission on Cancer (AJCC) stages I or II cancers (Q1); radiation within one year of diagnosis for women < 70 who received BCS (Q2); and radiation within one year of diagnosis for patients with ≥ 4 positive regional lymph nodes following mastectomy (Q3). Multivariable logistic regression and Cox proportional hazards models assessed receipt of each measure and overall survival, respectively, stratified by age group. Results Adherence was highest for Q1 (95-96%), followed by Q2 (76%) and Q3 (50-56%). Women 18-64 years with Medicaid or Medicare (vs. private) insurance were less likely to receive all quality measures [adjusted odds ratio (aORs): 0.52-0.68]. Women ≥ 65 years with Medicaid or Medicare were less likely to receive Q1 or Q2 (ORs: 0.54-0.88), although Q2 adherence with Medicare plus supplemental was similar to private insurance. Non-adherence was associated with worse overall survival across all quality measures. Conclusion Insurance-related disparities in care and survival persisted after ACA implementation, particularly among younger, publicly insured patients. While Medicare has improved access to care for older adults, disparities remain, highlighting the need to address these disparities to ensure equitable cancer care for all patients.