Clinical Investigation| Volume 364, ISSUE 2, P198-206, August 2022

Survival disparities among non-elderly American adults with locally advanced gastric cancer undergoing gastrectomy by health insurance status



      The impact of health insurance status on the survival outcomes of patients with locally advanced gastric cancer (LAGC) receiving gastrectomy have not been addressed in depth. We aim to identify definite associations of health insurance status with cancer-specific survival (CSS) and overall survival (OS) in this population.


      We identified LAGC patients aged 18 to 64 years undergoing gastrectomy with complete insurance records, between January 1, 2007, and December 31, 2016, from 18 Surveillance, Epidemiology, and End Results database registries. Relationships between health insurance status and OS/CSS were explored by Kaplan-Meier time-to-event analysis and uni-/multi-variate Cox regression. Probable baseline confounder was adjusted by multiple propensity score (mPS)-adjusted analysis.


      In total, 5,860 patients met the inclusion criteria. In the multivariate Cox regression, Medicaid coverage was related to poorer OS than private insurance. Non-insurance or Medicaid coverage versus private insurance tended to present poorer OS in the mPS-adjusted model, but this result was insignificant for CSS.


      Our observational study of exposure-outcome associations suggests that limited or no insurance is moderately linked with OS among LAGC patients undergoing gastrectomy and aged 18–64 years. Healthcare accessibility and broad insurance coverage probably strengthen some disparity outcomes.

      Key Indexing Terms

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of the Medical Sciences
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bray F.
        • Ferlay J.
        • Soerjomataram I.
        • et al.
        Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.
        CA Cancer J Clin. 2018; 68: 394-424
        • Torres J.
        • Correa P.
        • Ferreccio C.
        • et al.
        Gastric cancer incidence and mortality is associated with altitude in the mountainous regions of Pacific Latin America.
        Cancer Causes Control. 2013; 24: 249-256
        • Siegel R.L.
        • Miller K.D.
        • Jemal A.
        Cancer statistics, 2020.
        CA Cancer J Clin. 2020; 70: 7-30
        • Macdonald J.S.
        Gastric cancer–new therapeutic options.
        N Engl J Med. 2006; 355: 76-77
        • Kutlu O.C.
        • Watchell M.
        • Dissanaike S.
        Metastatic lymph node ratio successfully predicts prognosis in western gastric cancer patients.
        Surg Oncol. 2015; 24: 84-88
        • Li H.
        • Wei Z.
        • Wang C.
        • et al.
        Gender differences in gastric cancer survival: 99,922 cases based on the SEER database.
        J Gastrointest Surg. 2020; 24: 1747-1757
        • Wang J.
        • Sun Y.
        • Bertagnolli M.M.
        Comparison of gastric cancer survival between Caucasian and Asian patients treated in the United States: results from the Surveillance Epidemiology and End Results (SEER) database.
        Ann Surg Oncol. 2015; 22: 2965-2971
        • Lui F.H.
        • Tuan B.
        • Swenson S.L.
        • et al.
        Ethnic disparities in gastric cancer incidence and survival in the USA: an updated analysis of 1992-2009 SEER data.
        Dig Dis Sci. 2014; 59: 3027-3034
        • Yu J.
        • Huang C.
        • Sun Y.
        • et al.
        Effect of laparoscopic vs open distal gastrectomy on 3-year disease-free survival in patients with locally advanced gastric cancer: the CLASS-01 randomized clinical trial.
        JAMA. 2019; 321: 1983-1992
        • Han J.
        • Nie Z.
        • Li P.
        • et al.
        Comparison of treatment modalities for locally advanced gastric cancer: a propensity score matching analysis.
        J Cancer. 2020; 11: 4421-4430
        • Choi I.K.
        • Hyun J.J.
        • Kim S.Y.
        • et al.
        Influence of socioeconomic status on survival and clinical outcomes in patients with advanced gastric cancer after chemotherapy.
        Oncol Res Treat. 2014; 37: 310-314
        • Kuwahara A.
        • Takachi R.
        • Tsubono Y.
        • et al.
        Socioeconomic status and gastric cancer survival in Japan.
        Gastric Cancer. 2010; 13: 222-230
        • Andersen Z.J.
        • Lassen C.F.
        • Clemmensen IH.
        Social inequality and incidence of and survival from cancers of the mouth, pharynx and larynx in a population-based study in Denmark, 1994–2003.
        Eur J Cancer. 2008; 44: 1950-1961
        • Shi R.L.
        • Chen Q.
        • Yang Z.
        • et al.
        Marital status independently predicts gastric cancer survival after surgical resection-an analysis of the SEER database.
        Oncotarget. 2016; 7: 13228-13235
        • Sun W.
        • Cheng M.
        • Zhuang S.
        • et al.
        Impact of insurance status on stage, treatment, and survival in patients with colorectal cancer: a population-based analysis.
        Med Sci Monit. 2019; 25: 2397-2418
        • Nelson R.A.
        • Bostanci Z.
        • Jones V.
        • et al.
        Insurance status predicts survival in women with breast cancer: results of breast and cervical cancer treatment program in California.
        Ann Surg Oncol. 2020; 27: 2177-2187
        • Takenaka Y.
        • Yasui T.
        • Enomoto K.
        • et al.
        Health insurance status and survival among patients with head and neck cancer in Japan.
        Int J Clin Oncol. 2016; 21: 517-522
        • Wu C.C.
        • Hsu T.W.
        • Chang C.M.
        • et al.
        The effect of individual and neighborhood socioeconomic status on gastric cancer survival.
        PLoS One. 2014; 9: e89655
        • Jang J.S.
        • Shin D.G.
        • Cho H.M.
        • et al.
        Differences in the survival of gastric cancer patients after gastrectomy according to the medical insurance status.
        J Gastric Cancer. 2013; 13: 247-254
        • Zhu H.
        • Lu B.
        Multiple comparisons for survival data with propensity score adjustment.
        Comput Stat Data Anal. 2015; 86: 42-51
        • McCaffrey D.F.
        • Griffin B.A.
        • Almirall D.
        • et al.
        A tutorial on propensity score estimation for multiple treatments using generalized boosted models.
        Stat Med. 2013; 32: 3388-3414
        • Smith E.C.
        • Ziogas A.
        • Anton-Culver H.
        Delay in surgical treatment and survival after breast cancer diagnosis in young women by race/ethnicity.
        JAMA Surg. 2013; 148: 516-523
        • Wang N.
        • Cao F.
        • Liu F.
        • et al.
        The effect of socioeconomic status on health-care delay and treatment of esophageal cancer.
        J Transl Med. 2015; 13: 241
        • Harlan L.C.
        • Greene A.L.
        • Clegg L.X.
        • et al.
        Insurance status and the use of guideline therapy in the treatment of selected cancers.
        J Clin Oncol. 2005; 23: 9079-9088
        • Polite B.N.
        • Griggs J.J.
        • Moy B.
        • et al.
        American society of clinical oncology policy statement on medicaid reform.
        J Clin Oncol. 2014; 32: 4162-4167
        • Neugut A.I.
        • Subar M.
        • Wilde E.T.
        • et al.
        Association between prescription co-payment amount and compliance with adjuvant hormonal therapy in women with early-stage breast cancer.
        J Clin Oncol. 2011; 29: 2534-2542
        • Zafar S.Y.
        • Abernethy A.P.
        Financial toxicity, Part I: a new name for a growing problem.
        Oncology. 2013; 27 (Williston Park): 149
        • Zafar S.Y.
        • Peppercorn J.M.
        • Schrag D.
        • et al.
        The financial toxicity of cancer treatment: a pilot study assessing out-of-pocket expenses and the insured cancer patient's experience.
        Oncologist. 2013; 18: 381-390
        • Lillie-Blanton M.
        • Hoffman C.
        The role of health insurance coverage in reducing racial/ethnic disparities in health care.
        Health Aff. 2005; 24 (Millwood): 398-408
        • Ward E.
        • Halpern M.
        • Schrag N.
        • et al.
        Association of insurance with cancer care utilization and outcomes.
        CA Cancer J Clin. 2008; 58: 9-31
        • Benjamins M.R.
        • Whitman S.
        Relationships between discrimination in health care and health care outcomes among four race/ethnic groups.
        J Behav Med. 2014; 37: 402-413
        • Parker L.J.
        • Hunte H.
        • Ohmit A.
        Discrimination in health care: correlates of health care discrimination among black males.
        Am J Mens Health. 2017; 11: 999-1007
        • de Vries E.
        • Uribe C.
        • Pardo C.
        • et al.
        Gastric cancer survival and affiliation to health insurance in a middle-income setting.
        Cancer Epidemiol. 2015; 39: 91-96
        • Tehranifar P.
        • Neugut A.I.
        • Phelan J.C.
        • et al.
        Medical advances and racial/ethnic disparities in cancer survival.
        Cancer Epidemiol Biomark Prev. 2009; 18: 2701-2708
        • Freedman R.A.
        • Virgo K.S.
        • He Y.
        • et al.
        The association of race/ethnicity, insurance status, and socioeconomic factors with breast cancer care.
        Cancer. 2011; 117: 180-189
        • Wu X.C.
        • Lund M.J.
        • Kimmick G.G.
        • et al.
        Influence of race, insurance, socioeconomic status, and hospital type on receipt of guideline-concordant adjuvant systemic therapy for locoregional breast cancers.
        J Clin Oncol. 2012; 30: 142-150
        • Stessin A.M.
        • Sherr D.L.
        Demographic disparities in patterns of care and survival outcomes for patients with resected gastric adenocarcinoma.
        Cancer Epidemiol Biomark. Prev. 2011; 20: 223-233
        • Tsilimigras D.I.
        • Hyer J.M.
        • Diaz A.
        • et al.
        Impact of time-to-surgery on outcomes of patients undergoing curative-intent liver resection for BCLC-0, A and B hepatocellular carcinoma.
        J Surg Oncol. 2021; 123: 381-388
        • Visser E.
        • Leeftink A.G.
        • van Rossum P.S.
        • et al.
        Waiting time from diagnosis to treatment has no impact on survival in patients with esophageal cancer.
        Ann Surg Oncol. 2016; 23: 2679-2689
        • Nishida T.
        • Sugimoto A.
        • Tomita R.
        • et al.
        Impact of time from diagnosis to chemotherapy in advanced gastric cancer: a propensity score matching study to balance prognostic factors.
        World J Gastrointest Oncol. 2019; 11: 28-38
        • Brenkman H.
        • Visser E.
        • van Rossum P.
        • et al.
        Association between waiting time from diagnosis to treatment and survival in patients with curable gastric cancer: a population-based study in the Netherlands.
        Ann Surg Oncol. 2017; 24: 1761-1769
        • Bleicher R.J.
        • Ruth K.
        • Sigurdson E.R.
        • et al.
        Time to surgery and breast cancer survival in the United States.
        JAMA Oncol. 2016; 2: 330-339
        • Bradley C.J.
        • Gardiner J.
        • Given C.W.
        • et al.
        Cancer, Medicaid enrollment, and survival disparities.
        Cancer. 2005; 103: 1712-1718