Ann Surg Treat Res.  2019 Feb;96(2):58-69. 10.4174/astr.2019.96.2.58.

Prognostic influence of Korean public medical insurance system on breast cancer patients

• Hwang KT
• Ju YW
• Kim YA
• Kim J
• Oh S
• Jung J
• Chai YJ
• Choi IS
• Oh SW

• KMID: 2433942
• DOI: http://doi.org/10.4174/astr.2019.96.2.58

Abstract

PURPOSE
To investigate the prognostic influence of Korean public medical insurance system on breast cancer patients.
METHODS
Data of 1,068 patients with primary invasive breast cancer were analyzed. Korean public medical insurance status was classified into 2 groups: National Health Insurance and Medical Aid. Kaplan-Meier estimator and Cox proportional hazards model were used for survival analysis.
RESULTS
The Medical Aid group showed worse prognoses compared to the National Health Insurance group both in overall survival (P = 0.001) and recurrence-free survival (P = 0.006). The Medical Aid group showed higher proportion of patients with tumor size > 2 cm (P = 0.022), more advanced stage (P = 0.039), age > 50 years (P = 0.003), and low education level (P = 0.003). The Medical Aid group showed higher proportion of patients who received mastectomy (P < 0.001) and those who received no radiation therapy (P = 0.013). The Medical Aid group showed a higher rate of distant recurrence (P = 0.014) and worse prognosis for the triple negative subtype (P = 0.006). Medical insurance status was a significant independent prognostic factor in both univariate analysis and multivariate analysis.
CONCLUSION
The Medical Aid group had worse prognosis compared to the National Health Insurance group. Medical insurance status was a strong independent prognostic factor in breast cancer. Unfavorable clinicopathologic features could explain the worse prognosis for the Medical Aid group. Careful consideration should be given to medical insurance status as one of important prognostic factors for breast cancer patients.

Keyword

Breast neoplasms; Insurance; National Health Insurance; Prognosis

MeSH Terms

Breast Neoplasms*
Breast*
Education
Humans
Insurance Coverage
Insurance*
Mastectomy
Multivariate Analysis
National Health Programs
Prognosis
Proportional Hazards Models
Recurrence

Figure

• 

  Fig. 1 Survival curves according to medical insurance status in all subjects. Overall survival curves (A) and recurrence-free survival curves (B).

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  Fig. 2 Recurrence curves according to medical insurance status. Local recurrence (A), regional recurrence (B), distant recurrence (C), and contralateral breast recurrence (D).

• 

  Fig. 3 Overall survival curves according medical insurance status in patients with each breast cancer subtype. HRc(+)/HER2(−) (A), HRc(+)/HER2(+) (B), HRc(−)/HER2(+) (C), and HRc(−)/HER2(−) (D).

Reference

1. Roetzheim RG, Pal N, Tennant C, Voti L, Ayanian JZ, Schwabe A, et al. Effects of health insurance and race on early detection of cancer. J Natl Cancer Inst. 1999; 91:1409–1415.

2. Halpern MT, Ward EM, Pavluck AL, Schrag NM, Bian J, Chen AY. Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: a retrospective analysis. Lancet Oncol. 2008; 9:222–231.

3. Ward EM, Fedewa SA, Cokkinides V, Virgo K. The association of insurance and stage at diagnosis among patients aged 55 to 74 years in the national cancer database. Cancer J. 2010; 16:614–621.

4. Richardson LC. Treatment of breast cancer in medically underserved women: a review. Breast J. 2004; 10:2–5.

5. Grau JJ, Zanon G, Caso C, Gonzalez X, Rodriguez A, Caballero M, et al. Prognosis in women with breast cancer and private extra insurance coverage. Ann Surg Oncol. 2013; 20:2822–2827.

6. Inverso G, Mahal BA, Aizer AA, Donoff RB, Chuang SK. Health insurance affects head and neck cancer treatment patterns and outcomes. J Oral Maxillofac Surg. 2016; 74:1241–1247.

7. Parikh RR, Grossbard ML, Green BL, Harrison LB, Yahalom J. Disparities in survival by insurance status in patients with Hodgkin lymphoma. Cancer. 2015; 121:3515–3524.

8. Markt SC, Lago-Hernandez CA, Miller RE, Mahal BA, Bernard B, Albiges L, et al. Insurance status and disparities in disease presentation, treatment, and outcomes for men with germ cell tumors. Cancer. 2016; 122:3127–3135.

9. Ortiz-Ortiz KJ, Ramirez-Garcia R, Cruz-Correa M, Rios-Gonzalez MY, Ortiz AP. Effects of type of health insurance coverage on colorectal cancer survival in Puerto Rico: a population-based study. PLoS One. 2014; 9:e96746.

10. Lee JM, Wang X, Ojha RP, Johnson KJ. The effect of health insurance on childhood cancer survival in the United States. Cancer. 2017; 123:4878–4885.

11. Aizer AA, Falit B, Mendu ML, Chen MH, Choueiri TK, Hoffman KE, et al. Cancer-specific outcomes among young adults without health insurance. J Clin Oncol. 2014; 32:2025–2030.

12. Ellis L, Canchola AJ, Spiegel D, Ladabaum U, Haile R, Gomez SL. Trends in cancer survival by health insurance status in California from 1997 to 2014. JAMA Oncol. 2018; 4:317–323.

13. Song SO, Jung CH, Song YD, Park CY, Kwon HS, Cha BS, et al. Background and data configuration process of a nationwide population-based study using the korean national health insurance system. Diabetes Metab J. 2014; 38:395–403.

14. Kim JA, Yoon S, Kim LY, Kim DS. Towards actualizing the value potential of Korea Health Insurance Review and Assessment (HIRA) data as a resource for health research: strengths, limitations, applications, and strategies for optimal use of HIRA data. J Korean Med Sci. 2017; 32:718–728.

15. Hsu CD, Wang X, Habif DV Jr, Ma CX, Johnson KJ. Breast cancer stage variation and survival in association with insurance status and sociodemographic factors in US women 18 to 64 years old. Cancer. 2017; 123:3125–3131.

16. Niu X, Roche LM, Pawlish KS, Henry KA. Cancer survival disparities by health insurance status. Cancer Med. 2013; 2:403–411.

17. Ayanian JZ, Kohler BA, Abe T, Epstein AM. The relation between health insurance coverage and clinical outcomes among women with breast cancer. N Engl J Med. 1993; 329:326–331.

18. Coburn N, Fulton J, Pearlman DN, Law C, DiPaolo B, Cady B. Treatment variation by insurance status for breast cancer patients. Breast J. 2008; 14:128–134.

19. Amini A, Jones BL, Yeh N, Guntupalli SR, Kavanagh BD, Karam SD, et al. Disparities in disease presentation in the four screenable cancers according to health insurance status. Public Health. 2016; 138:50–56.

20. Churilla TM, Egleston B, Bleicher R, Dong Y, Meyer J, Anderson P. Disparities in the local management of breast cancer in the US according to health insurance status. Breast J. 2017; 23:169–176.

21. Halpern MT, Bian J, Ward EM, Schrag NM, Chen AY. Insurance status and stage of cancer at diagnosis among women with breast cancer. Cancer. 2007; 110:403–411.

22. Walker GV, Grant SR, Guadagnolo BA, Hoffman KE, Smith BD, Koshy M, et al. Disparities in stage at diagnosis, treatment, and survival in nonelderly adult patients with cancer according to insurance status. J Clin Oncol. 2014; 32:3118–3125.

23. Chen HL, Zhou MQ, Tian W, Meng KX, He HF. Effect of age on breast cancer patient prognoses: a population-based study using the SEER 18 database. PLoS One. 2016; 11:e0165409.

24. Zhu W, Perez EA, Hong R, Li Q, Xu B. Age-related disparity in immediate prognosis of patients with triple-negative breast cancer: a population-based study from SEER cancer registries. PLoS One. 2015; 10:e0128345.

25. Albano JD, Ward E, Jemal A, Anderson R, Cokkinides VE, Murray T, et al. Cancer mortality in the United States by education level and race. J Natl Cancer Inst. 2007; 99:1384–1394.

26. Hussain SK, Altieri A, Sundquist J, Hemminki K. Influence of education level on breast cancer risk and survival in Sweden between 1990 and 2004. Int J Cancer. 2008; 122:165–169.

27. Hwang KT, Noh W, Cho SH, Yu J, Park MH, Jeong J, et al. Education level is a strong prognosticator in the subgroup aged more than 50 years regardless of the molecular subtype of breast cancer: a study based on the nationwide Korean Breast Cancer Registry Database. Cancer Res Treat. 2017; 49:1114–1126.

28. DeSantis C, Jemal A, Ward E. Disparities in breast cancer prognostic factors by race, insurance status, and education. Cancer Causes Control. 2010; 21:1445–1450.