The Effect of Insurance Status on Treatment Modality in Advanced Oral
Cavity Cancer
Abstract
Objectives: Insurance status has been shown to impact survival outcomes.
We sought to determine whether insurance affects the choice of treatment
modality among patients with advanced (T4) oral cavity squamous cell
carcinoma (OCSCC). Design: Retrospective, population-based cohort study
Setting: The Survival, Epidemiology, and End Results (SEER) Program
database Participants: The population included all adult (age
> 18) patients with advanced (T4a or T4b) OCSCC diagnosed
from 2007 to 2016. Main outcome measures: The main outcome measure was
the odds of receiving definitive treatment, defined as primary surgical
resection. Insurance status was categorized into uninsured, any
Medicaid, and insured groups. Univariable, multivariable, and subgroup
analyses were performed. Results: The study population consisted of 2628
patients, of whom 1915 (72.9%) were insured, 561 (21.3%) had Medicaid,
and 152 (5.8%) were uninsured. The multivariable model showed that
patients who were 80 years or older, unmarried, with T4b disease,
received treatment in the pre-Affordable Care Act (ACA) period, and who
were on Medicaid or uninsured were significantly less likely to receive
definitive treatment. Among patients with T4a disease, insured patients
were significantly more likely to receive definitive treatment compared
to those on Medicaid or uninsured (OR=0.69, 95% CI 0.54-0.88,
p<0.0001 [Medicaid vs. Insured]; and OR=0.65, 95% CI
0.43-0.98, p=0.001 [Uninsured vs. Insured]), however these
differences did not persist when considering only those patients treated
following the 2014 expansion of the ACA. Conclusions: Insurance status
is significantly associated with treatment modality among adults with
advanced stage (T4a) OCSCC. These findings support the premise of
expanding insurance coverage in the United States.