Lack of access to chemotherapy for colon cancer: multiplicative disadvantage of being extremely poor, inadequately insured and African American

Kevin M Gorey,Frances C Wright,Sindu M Kanjeekal,Sundus Haji-Jama,Isaac N Luginaah,Emma Bartfay

doi:10.1186/1472-6963-14-133

Abstract

BackgroundDespite evidence of chemotherapy’s ability to cure or comfort those with colon cancer, nearly half of such Americans do not receive it. African Americans (AA) seem particularly disadvantaged. An ethnicity by poverty by health insurance interaction was hypothesized such that the multiplicative disadvantage of being extremely poor and inadequately insured is worse for AAs than for non-Hispanic white Americans (NHWA).MethodsCalifornia registry data were analyzed for 459 AAs and 3,001 NHWAs diagnosed with stage II to IV colon cancer between 1996 and 2000 and followed until 2011. Socioeconomic data from the 2000 census categorized neighborhoods: extremely poor (≥ 30% of households poor), middle (5-29% poor) and low poverty (< 5% poor). Participants were randomly selected from these poverty strata. Primary health insurers were Medicaid, Medicare, private or none. Chemotherapy rates were age and stage-adjusted and comparisons used standardized rate ratios (RR). Logistic and Cox regressions, respectively, modeled chemotherapy receipt and long term survival.ResultsA significant 3-way ethnicity by poverty by health insurance interaction effect on chemotherapy receipt was observed. Among those who did not live in extremely poor neighborhoods and were adequately insured privately or by Medicare, chemotherapy rates did not differ significantly between AAs (37.7%) and NHWAs (39.5%). Among those who lived in extremely poor neighborhoods and were inadequately insured by Medicaid or uninsured, AAs (14.6%) were nearly 60% less likely to receive chemotherapy than were NHWAs (25.5%, RR = 0.41). When the 3-way interaction effect as well as the main effects of poverty, health insurance and chemotherapy was accounted for, survival rates of AAs and NHWAs were the same.ConclusionsThe multiplicative barrier to colon cancer care that results from being extremely poor and inadequately insured is worse for AAs than it is for NHWAs. AAs are more prevalently poor, inadequately insured, and have fewer assets so they are probably less able to absorb the indirect and direct, but uncovered, costs of colon cancer care. Policy makers ought to be cognizant of these factors as they implement the Affordable Care Act and consider future health care reforms.

Highlights

Despite evidence of chemotherapy’s ability to cure or comfort those with colon cancer, nearly half of such Americans do not receive it
At the top of the table it can be seen that among those who did not live in extremely poor neighborhoods and were adequately insured, chemotherapy rates did not differ significantly between AAs and non-Hispanic white Americans (NHWA)
AAs, those who lived in extremely poor neighborhoods and those who were inadequately insured were all significantly less likely than NHWAs, the less poor or the adequately insured to receive chemotherapy and so more likely to die sooner

Summary

Introduction

Despite evidence of chemotherapy’s ability to cure or comfort those with colon cancer, nearly half of such Americans do not receive it. An ethnicity by poverty by health insurance interaction was hypothesized such that the multiplicative disadvantage of being extremely poor and inadequately insured is worse for AAs than for non-Hispanic white Americans (NHWA). African Americans (AA), who are poorer and less adequately insured, on average, than non-Hispanic white Americans (NHWA), seem disadvantaged [6,7]. They are less likely to receive adjuvant chemotherapy and this can explain much of their survival disadvantage [5,8,9,10]

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Conclusion