Mixed effects of area-level deprivation and healthcare access and individual-level health insurance on late-stage colorectal cancer diagnosis in Pennsylvania.

BACKGROUND

Despite screenings successful reduction of colorectal cancer (CRC) incidence, about one-third of diagnoses in the United States are late-stage, negatively impacting survival rates. Furthermore, Pennsylvania CRC incidence and mortality has been consistently above national rates even with screening coverage from the Affordable Care Act and Medicaid expansion.

PURPOSE: Investigate the role of area-level deprivation, healthcare access, and individual factors, including health insurance status, on late-stage CRC.

METHODS

Screening age-eligible adults diagnosed with a primary CRC (2008-2017) were identified from Pennsylvania Cancer Registry data (N = 34,250). Late-stage CRC combines "Distant" and "Regional" stage diagnoses defined by the National Cancer Institute's Summary Staging. Area-level healthcare access was estimated using a Multi-modal Two-Step Floating Catchment Area, and neighborhood deprivation via Weighted Quantile Sum regression. The risk of late-stage CRC in association with insurance coverage (private, government, none), was modeled using spatial two-level generalized linear mixed models, adjusted for individual age, sex, race/ethnicity, rurality, and area-level deprivation and healthcare access.

RESULTS

Compared to having private health insurance, individuals with government insurance were more likely to be diagnosed with late stage during the 2010-2013 and 2014-2017 time periods (OR range=1.12-1.19). Having no health insurance (OR range=2.10-2.69 vs. private health insurance) was significantly associated with increased likelihood of late-stage diagnosis at all three time periods (2008-2009, 2010-2013, 2014-2017). Late-stage CRC was significantly less likely among older individuals (OR range=0.98-0.99), Black (OR range=0.80-0.85) and other race (OR=0.57) vs. white race, and suburban (OR=0.78) vs. urban residence and varying by time period. Area-level deprivation and healthcare access was not significantly associated with late-stage CRC diagnosis.

CONCLUSION

Health insurance type appears to be a major factor associated with late-stage CRC diagnosis in Pennsylvania, independent of age, sex, race/ethnicity, rurality, area-level deprivation, and healthcare access. Given CRC is covered for preventive screening by the Affordable Care Act and Pennsylvania's Medicaid expansion, these results suggest improving health insurance coverage awareness and utilization may reduce incidence and mortality from late-stage CRC.