Impact of insurance type on outcomes after radical cystectomy for bladder cancer.
Authors: Doshi Chirag , Zahir Mazyar , Dadabhoy Anosh , Escobar Domenique , Miranda Gus , Cai Jie , Djaladat Hooman , Schuckman Anne K. , Daneshmand Siamak 
Published: February 2025

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Background:
A patient’s insurance status can significantly impact their access to care, potentially altering their treatment course and outcomes. This study aimed to evaluate the potential influence of different insurance statuses on oncological outcomes, including survival.
Methods:
We utilized our prospectively maintained IRB-approved radical cystectomy (RC) database (#HS-01B014) to identify all muscle invasive bladder cancer (MIBC) patients who underwent neoadjuvant chemotherapy (NAC) followed by RC from 2000 to 2023. Patients were then categorized based on primary insurance type to Preferred Provider Organizations (PPO), Health Maintenance Organizations (HMO), Medicare, MediCal, and Self-Pay. We extracted demographic, clinical, and oncological outcomes data from our database. All statistical analyses were performed using SAS Version 9.4 (SAS Institute Inc., Cary, NC, USA).
Results:
A total of 432 patients were included in the final analyses. Patient demographics and baseline characteristics are shown in Table 1. Patients were followed for a median of 42.0 months after cystectomy. On univariate cox regression, PPO insurance was associated with improved OS (Hazards Ratio (HR) = 0.47 [95%CI: 0.29, 0.75], p = .002) and RFS (HR = 0.48 [95%CI: 0.30, 0.78], p = .003) compared to the reference group, Medicare. A multivariate cox regression demonstrated that PPO health plan could enhance OS (HR = 0.49 [95%CI: 0.30, 0.78]) even after adjusting for pathological stage. Having any other health plan had neither a beneficial, nor a detrimental effect on OS or RFS.
Conclusions:
Better insurance coverage is associated with improved OS and RFS. However, the single institutional design of our study limits the generalizability of our findings. Larger prospective multi-institutional studies are encouraged to better evaluate how insurance status and socioeconomic disparities can affect survival outcomes in MIBC.

Demographics and baseline clinical characteristics stratified by insurance status.

Variables
Medicare (n = 190)
HMO (n = 85)
PPO (n =143)
MediCal (n = 10)
Self-pay (n=4)
p-value

Gender (Male)
148 (77.9%)
69 (81.2%)
117 (81.8%)
8 (80.0%)
3 (75.0%)
.917

Age at diagnosis (yrs.)
71.5 ± 6.4
64.6 ± 10.0
60.2 ± 8.6
55.7 ± 12.9
54.8 ± 14.6
<.001

Charlson Comorbidity Index
0
30 (15.8%)
26 (30.6%)
55 (38.4%)
3 (30.0%)
1 (25.0%)
<.001

1
52 (27.4%)
16 (18.8%)
35 (24.5%)
4 (40.0%)
2 (50.0%)

≥ 2
108 (56.8%)
43 (50.6%)
53 (37.1%)
3 (30.0%)
1 (25.0%)

Pathological staging
< (y)pT2; pN0
115 (60.5%)
59 (69.4%)
94 (65.7%)
4 (40.0%)
2 (50.0%)
.515

> (y)pT2; pN0
34 (17.9%)
9 (10.6%)
25 (17.5%)
2 (20.0%)
1 (25.0%)

pN+
41 (21.6%)
17 (20.0%)
24 (16.8%)
4 (40.0%)
1 (25.0%)

Income percentiles
0 - 40th
20 (10.5%)
13 (15.3%)
14 (9.8%)
4 (40.0%)
0 (0.0%)
.193

40 - 60th
56 (29.5%)
26 (30.6%)
39 (27.3%)
4 (40.0%)
1 (25.0%)

60 - 80th
76 (40.0%)
33 (38.8%)
58 (40.6%)
2 (20.0%)
2 (50.0%)

80 - 100th
38 (20.0%)
13 (15.3%)
32 (22.4%)
0 (0.0%)
2 (50.0%)