Abstract 4465: The effect of insurance status on childhood and adolescent cancer survival using data from the National Cancer Database

Background Differences in access, delivery or utilization of health care may impact childhood and adolescent cancer survival. In this study, we evaluated the impact of insurance coverage on survival among children and adolescents diagnosed with cancer, and explored potential mechanisms. Methods We obtained data from 58,421 individuals diagnosed with any cancer type at ≤ 19 years old from 2004-2010 from the National Cancer Database. We examined associations between insurance status at diagnosis or initial treatment and stage at diagnosis, treatment received (any vs. none), and all-cause mortality using logistic regression, Cox proportional hazards regression, restricted mean survival time and mediation analyses for all cancers combined and by cancer type. We evaluated the moderation effect of age on cancer death in association with insurance status using the likelihood-ratio test. Results Children and adolescents with Medicaid, unknown insurance, and those who were uninsured were more likely to be non-White, from lower income counties, be diagnosed at an advanced stage, and less likely to receive any treatment than those with private insurance. Those with Medicaid, unknown insurance, and who were uninsured had a 27% (95%CI, 1.22 to 1.33), 39% (95%CI, 1.26 to 1.53), and 32% (95%CI, 1.20 to 1.46) higher hazard of death during 5 years of follow-up versus those with private insurance. Survival at 60 months was modestly lower for these groups than those who were privately insured at 1.73 months (95%CI, -2.07 to -1.38), 2.48 months (95%CI, -3.29 to -1.68), and 2.13 months (95%CI, -2.91 to -1.34). The higher mortality risk and lower survival months in non-privately insured cases were observed for most cancer types. In mediation analyses, for Medicaid and uninsured patients, earlier diagnosis for staged cancers was estimated to reduce the survival deficit by approximately one fourth and one half. Treatment did not account for the insurance associated survival difference. Conclusion Enhancing existing insurance coverage and ensuring equal and early diagnosis may help to improve survival overall for children and adolescents diagnosed with cancer. Future qualitative studies are needed to understand institutional and family level barriers to diagnosis and care of children with cancer and to further explain the underlying mechanisms for differences in childhood survival by insurance status. Citation Format: Xiaoyan Wang, Rohit P. Ojha, Kimberly J. Johnson. The effect of insurance status on childhood and adolescent cancer survival using data from the National Cancer Database [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4465.