Abstract
Little is known about how health insurance policies, particularly in developing countries, influence breast cancer prognosis. Here, we examined the association between individual health insurance and breast cancer-specific mortality in China. We included 7436 women diagnosed with invasive breast cancer between 2009 and 2016, at West China Hospital, Sichuan University. The health insurance plan of patient was classified as either urban or rural schemes and was also categorized as reimbursement rate (ie, the covered/total charge) below or above the median. Breast cancer-specific mortality was the primary outcome. Using Cox proportional hazards models, we calculated hazard ratios (HRs) for cancer-specific mortality, contrasting rates among patients with a rural insurance scheme or low reimbursement rate to that of those with an urban insurance scheme or high reimbursement rate, respectively. During a median follow-up of 3.1 years, we identified 326 deaths due to breast cancer. Compared to patients covered by urban insurance schemes, patients covered by rural insurance schemes had a 29% increased cancer-specific mortality (95% CI 0%-65%) after adjusting for demographics, tumor characteristics and treatment modes. Reimbursement rate below the median was associated with a 42% increased rate of cancer-specific mortality (95% CI 11%-82%). Every 10% increase in the reimbursement rate is associated with a 7% (95% CI 2%-12%) reduction in cancer-specific mortality risk, particularly in patients covered by rural insurance schemes (26%, 95% CI 9%-39%). Our findings suggest that underinsured patients face a higher risk of breast cancer-specific mortality in developing countries.
Highlights
Battling cancer is a crushing burden for all patients, but so for those who are vulnerable to financial stress
Leveraging a prospective large-scale cohort of patients with invasive breast cancer in China diagnosed from 2009 to 2016, we aimed to examine the associations of health insurance types and reimbursement rates with the risks of breast cancer-specific mortality
We identified 7623 female patients who were diagnosed with invasive breast cancer at West China Hospital (WCH), Sichuan University from January 1, 2009, to December 31, 2016, based on the Breast Cancer Information Management System (BCIMS)
Summary
Battling cancer is a crushing burden for all patients, but so for those who are vulnerable to financial stress. Cancer patients have higher out-of-pocket costs and may be absent from work for quite a while, which further lowers the ability to pay for medical care.[1,2] As an avalanche of “financial toxicity”—the damaging economic side effects of illness, cancer patients are at tremendous risk for debt, bankruptcy and impaired psychological wellbeing.[3,4] It is well-documented that social inequality in health contributes to the disparities in cancer survivorship in both developed and developing countries, including China.[5,6,7,8] The presence of a public health insurance system seems essential for a country to achieve universal healthcare coverage and health equity.[9] Improved health insurance coverage can reduce sociodemographic disparities in cancer care, including breast cancer, through early diagnosis and optimal treatment.[10,11] Fewer studies have paid attention to the impact of health insurance on cancer prognosis. Leveraging a prospective large-scale cohort of patients with invasive breast cancer in China diagnosed from 2009 to 2016, we aimed to examine the associations of health insurance types and reimbursement rates with the risks of breast cancer-specific mortality
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