Young adults, cancer, health insurance, socioeconomic status, and the Patient Protection and Affordable Care Act

During the last 50 years, the majority of improvements in survival in Americans with cancer have been noted in children and older adults and not in older adolescent and young adult (AYA) patients. When evaluated by 5-year age intervals, the increase in the 5-year relative survival rate in the United States during the 3 decades since 1975 has been lower for all age groups between ages 15 years and 45 years than any of the other groups aged <85 years (Fig. 1 Top). Moreover, the AYA deficit has improved less during the second one-half of the 30 years (1989-2003) compared with the first one-half (1975-1988) (Fig. 1 Bottom). The lack of recent progress is particularly evident in those aged 15 years to 25 years, whose survival prolongation has slowed to the point of their being the only group aged<75 years lacking a statistically significant increase in survival (Fig. 1, lowest row of P values). In the United States, the number of deaths due to cancer declined in all age groups during the past decade except in individuals aged 15 years to 29 years and in those 25 years to 29 years it increased. Among those aged 15 years to 39 years, cancer became the most common cause of death due to disease in 1997, accounting since then for 10% of all deaths and 22% of all deaths due to natural causes (excluding accidents, homicides, and suicides). The reasons for the lack of progress in AYAs has been the subject of national scrutiny since 2005, when the National Cancer Institute and the Lance Armstrong Foundation conducted a Progress Review Group in AYA oncology. A variety of deficits in the AYA age group have been implicated, including clinical trial activity, biospecimens for translational research, the training of medical professionals in AYA oncology, the distinctive array of AYA cancers, and the unique psychosocial and financial challenges faced by AYAs, especially health insurance. Five years ago, we reported a study of the lag time from the onset of first cancer-specific symptoms or signs to a definitive diagnosis in 270 patients aged 15 years to 29 years at The University of Texas MD Anderson Cancer Center in Houston who were newly diagnosed between June 2001 and June 2003 with 6 common cancer types. On multivariate analysis, insurance status was found to be significantly associated with lag time, whereas race/ethnicity, age, gender, marital status, and surrogate measures of socioeconomic status (SES) were not. The mean lag time was 7 weeks longer in underinsured patients compared with privately insured patients (odds ratio [OR], 1.63; P < .01). In all 6 histology-specific cancer types, the mean lag time was found to be longer (between 23 days and 148 days depending on the tumor type) in underinsured patients and in 4 cancer types, the difference was statistically significant. In cancers that were evaluable for stage at diagnosis, an advanced stage of disease was associated with longer lag times. We concluded that inadequate health insurance in AYAs with cancer increases the risk of a delay in diagnosis and advanced disease. In a study published in this issue of Cancer by Smith et al at the University of California at Irvine, the demographics of 7343 incident cases of Hodgkin lymphoma (HL) in the California Cancer Registry that were diagnosed between 1988 and 2006 in patients between the ages of 15 years and 40 years were evaluated for gender, race, birthplace, marital status, SES, and insurance status as potential obstacles to detection at an early stage of disease. Onmultivariate logistic regression