Effects of health insurance and race on colorectal cancer treatments and outcomes.

Objectives. We hypothesized that health insurance payer and race might influence the care and outcomes of patients with colorectal cancer. Methods. We examined treatments received for all incident cases of colorectal cancer occurring in Florida in 1994 (n=9551), using state tumor registry data. We also estimated the adjusted risk of death (through 1997), using proportional hazards regression analysis controlling for other predictors of mortality. Results. Treatments received by patients varied considerably according to their insurance payer. Among non-Medicare patients, those in the following groups had higher adjusted risks of death relative to commercial fee-for-service insurance: commercial HMO (risk ratio [RR] = 1.40; 95% confidence interval [CI] = 1.18, 1.67; P = .0001), Medicaid (RR=1.44; 95% CI=1.06, 1.97; P=.02), and uninsured (RR=1.41; 95% CI=1.12, 1.77; P = .003). Non-Hispanic African Americans had higher mortality rates (RR=1.18; 95% CI=1.01, 1.37; P=.04) than non-Hispanic Whites. Conclusions. Patients with colorectal cancer who were uninsured or insured by Medicaid or commercial HMOs had higher mortality rates than patients with commercial fee-for-service insurance. Mortality was also higher among nonHispanic African American patients. (Am J Public Health. 2000;90:1746‐1754) Colorectal cancer is the second leading cause of cancer mortality in the United States, with an estimated 132000 cases diagnosed in 1998 and 57000 deaths in the same year. 1 Although detection of colorectal cancer at an early stage is critical to achieving good outcomes, proper treatment can also influence survival. In addition to surgical excision of the primary tumor, many patients benefit from adjuvant chemotherapy or radiation therapy. 2‐11 Previous studies have shown great variability in the care and outcome of patients with colorectal cancer. 12,13 Age-adjusted colon cancer mortality rates are significantly higher for Black patients than for White patients. 14‐16 Colorectal cancer mortality rates are falling among White patients but rising among Black patients. 14 Disparate treatments have been suggested as one factor contributing to racial differences in survival. 17