Introduction & Objectives
Mortality from cancer appears to be due to a complex of demographic and clinical factors of which insurance is a part.
We looked at 257 patients undergoing radical cystectomy and compared their presenting characteristics and their mortality rates, all cause, disease specific and progression rates between those treated in the national health service (NHS) and those with private health insurance (PHI).
Material & Methods
Various characteristics were compared using Fishers and t tests.
Kaplan Meier curves were generated for the two cohorts for progression and mortality and logistic regression applied to generate significant predictors. The operations were all performed by the same surgeon.
|Characteristic||NHS n = 225||PHI n = 32||P|
|Tumour volume cc||22||11||0.18|
|Positive surgical margins||32 (14%)||2 (6%)||0.27|
|Stage localised |
|146 (56%) |
|20 (62%) |
|Carcinoma in situ||92 (41%)||19 (59%)||0.057|
|Mean number of nodes dissected||9||13||0.006|
|Patients with nodal involvement||43 (19%)||7 (22%)||0.811|
|Nodal extracapsular extension||24/43||4/7||1.0|
|Complications||89 (40%)||4 (13%)||0.002|
|Additional treatment given||38 (17%)||4 (13%)||0.79|
|Neobladder||40 (18%)||12 (38%)||0.16|
|All cause mortality|
|Disease specific mortality|
The PHI cohort generated negative protective coefficents on all three survival analyses.
PHI younger, with more nodes taken during nodal dissection and have less complications.
Regarding prognosis, PHI was a significant protective risk variable for ACM (OR 0.24), DSM (OR 0.33) and PFM (0.14).
Also (but not statistically significant), those with PHI had smaller tumours, less PSM, less locally advanced disease, less additional treatments (adjuvant, neoadjuvant, radiotherapy and chemotherapy), more neobladders and more CIS.
However, stage, additional treatment and neobladder were all significant predictors of survival. These were all favourable in those with PHI.
The higher ACM may be due to overall poorer health, more comorbidities, unhealthy behaviour? Inadequate preventive health care, poor management of chronic conditions, barriers to receiving treatment, inability to navigate health care system, high cost, misinformation and distrust of healthcare system, lack of transport, lack of time off work. Lower quality of treatment offered by providers serving Medicaid and uninsured. Further, there is no lead time bias (perceived increased survival time with no effect on course of cancer) with bladder cancer as there is no screening protocol, unlike prostate.
This study shows significant differences in prognosis post cystectomy to those treated in the NHS and those treated privately.