Abstract B87: The impact of insurance and treatment on racial differences in uterine cancer survival: A study of patients in the National Cancer Database
Authors: Fedewa Stacey A. , Lerro Catherine , Chase Dana , Ward Elizabeth M. 
Published: December 2010

Abstract
Introduction: Among uterine cancer patients, the age-adjusted mortality for African Americans is substantially higher relative to white patients. Previous studies have attributed this survival disparity to an elevated rate of aggressive tumors and advanced stage of disease among African Americans. However, the role of access to care in this racial disparity has not been fully elucidated. The aim of this study is to examine the impact of insurance status and treatment on racial/ethnic survival disparities among a large cohort of uterine cancer patients from the National Cancer Database (NCDB).
Methods: Women diagnosed with stage I-III uterine cancer between 2000-2007 were selected from the NCDB. The association between race/ethnicity and all cause mortality was analyzed adjusting for patient demographic and clinical factors, health insurance, treatment (which included categories for no surgery, surgery alone, and surgery plus systemic treatment), area-level education, and facility characteristics. Kaplan Meir (KM) and multivariate Cox proportional hazards were used to estimate 4 year survival rates and hazard ratios (HR) and 95% confidence intervals (CI) among patients diagnosed between 2000-2002, respectively. Log binomial models were used to estimate risk ratios (RR) and 95% CI of likelihood of surgical treatment and among patients receiving surgery, the risk of lymphadectomy and systemic (radiation and/or chemotherapy) therapy.
Results: Among the 178,891 evaluable patients, 73.79%, 4.39% 8.66%, 3.07% and 10.08% were white, Hispanic, African American, Other and missing race. The 4 year survival rate was 81.81% for whites, 81.50% for Hispanic, 63.19% for African American and 85.62% for other races. African Americans had a higher risk of death compared to whites (HR=1.43 95%CI1.31 −1.56) after adjusting for all covariates except treatment and insurance. After additional adjustment of treatment the risk death decreased among African Americans (HR=1.32 95%CI1.21 −1.45) and subsequent adjustment for insurance further reduced the hazard of death (HR=1.28 95% CI1.16-1.40). Patients with insurance other than private had an increased risk of death (Uninsured HR= 1.46 95%CI1.22-1.75, Medicaid HR=1.74,95%CI1.49-2.02, Medicare among patients aged 18-64 HR=2.52,95% CI 2.13-2.99, Medicare among patients aged 65-99 HR=1.26,95% 1.16-1.38). African Americans (RR= 0.96 95% CI 0.96-0.97) and Hispanics (RR=0.99 95% CI 0.99-1.00) had similar surgical treatment rates compared to whites and among patients receiving surgical treatment, similar rates of lymphadectomy and systemic treatment by race/ethnicity were observed.
Conclusions: Our results suggest that a portion of the survival disparity between African Americans and whites is attributable to variations in access to care; the hazard ratios of death decreased 11% when treatment was accounted for and an additional 4% when insurance was accounted for. Despite accounting for these and other factors, African American patients had 32% greater risk of death. Future studies examining the role of lifestyle factors and non insurance related barriers to medical care, such as lower income, prior experiences and trust in the health care system, language and geographic barriers, cultural and communication barriers are warranted.
Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):B87.