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Original Investigation
September 2017

Association of Insurance and Community-Level Socioeconomic Status With Treatment and Outcome of Squamous Cell Carcinoma of the Pharynx

Author Affiliations
  • 1Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois
  • 2School of Dentistry, University of Michigan, Ann Arbor
JAMA Otolaryngol Head Neck Surg. 2017;143(9):899-907. doi:10.1001/jamaoto.2017.0837
Key Points

Question  What is the association of insurance and community-level socioeconomic status with outcomes for patients with squamous cell carcinoma of the pharynx?

Findings  In this study of the National Cancer Database records of 35 559 patients with squamous cell carcinoma of the pharynx, patients with private insurance or higher household income had earlier disease status at presentation, were likely to start their primary treatment earlier, and had better outcomes compared with patients who were uninsured or had lower household income.

Meaning  Insurance status and household income level are important independent prognosticators for overall survival.


Importance  Community-level socioeconomic status, particularly insurance status, is increasingly becoming important as a possible determinant in patient outcomes.

Objective  To determine the association of insurance and community-level socioeconomic status with outcome for patients with pharyngeal squamous cell carcinoma (SCC).

Design, Setting, and Participants  This study extracted data from more than 1500 Commission on Cancer–accredited facilities collected in the National Cancer Database. A total of 35 559 patients diagnosed with SCC of the pharynx from 2004 through 2013 were identified. The χ2 test, Kaplan-Meier method, and Cox regression models were used to analyze data from April 1, 2016, through April 16, 2017.

Main Outcomes and Measures  Overall survival was defined as time to death from the date of diagnosis.

Results  Among the 35 559 patients identified (75.6% men and 24.4% women; median age, 61 years [range, 18-90 years]), 15 146 (42.6%) had Medicare coverage; 13 061 (36.7%), private insurance; 4881 (13.7%), Medicaid coverage; and 2471 (6.9%), no insurance. Uninsured patients and Medicaid recipients were more likely to be younger, black, or Hispanic; to have lower median household income and lower educational attainment; to present with higher TNM stages of disease; and to start primary treatment at a later time from diagnosis. Those with private insurance (reference group) had significantly better overall survival than uninsured patients (hazard ratio [HR], 1.72; 95% CI, 1.59-1.87), Medicaid recipients (HR, 1.99; 95% CI, 1.88-2.12), or Medicare recipients (HR, 2.07; 95% CI, 1.99-2.16), as did those with median household income of at least $63 000 (reference) vs $48 000 to $62 999 (HR, 1.19; 95% CI, 1.13-1.26), $38 000 to $47 999 (HR, 1.31; 95% CI, 1.24-1.38), and less than $38 000 (HR, 1.51; 95% CI, 1.43-1.59). On multivariable analysis, insurance status and median household income remained independent prognostic factors for overall survival even after accounting for educational attainment, race, Charlson/Deyo comorbidity score, disease site, and TNM stage of disease.

Conclusions and Relevance  Insurance status and household income level are associated with outcome in patients with SCC of the pharynx. Those without insurance and with lower household income may significantly benefit from improving access to adequate, timely medical care. Additional investigations are necessary to develop targeted interventions to optimize access to standard medical treatments, adherence to physician management recommendations, and subsequently, prognosis in these patients at risk.