236980 Observational evidence of much better cancer care among extremely poor Canadians than Americans

Tuesday, November 1, 2011

Kevin M. Gorey, PhD, MSW , School of Social Work, University of Windsor, Windsor, ON, Canada
Isaac N. Luginaah, PhD , Department of Geography, University of Western Ontario, London, ON, Canada
Madhan K. Balagurusamy, MSc , Department of Mathematics and Statistics, University of Windsor, Windsor, ON, Canada
Frances C. Wright, MD, MEd , Department of Surgery and the Department of Health Care Policy and Management, Sunnybrook Health Sciences Center and the University of Toronto, Toronto, ON, Canada
Caroline Hamm, MD , Department of Medical Oncology, Windsor Regional Cancer Center, Windsor, ON, Canada
Sindu M. Kanjeekal, MD , Department of Medical Oncology, Windsor Regional Cancer Center, Windsor, ON, Canada
Cancer care has been observed to be advantaged in studies of near poor to poor Canadian versus similar United States contexts. However, none of them studied extremely impoverished, so-called “underclass” neighborhoods. This retrospective cohort study did. It examined the differential effects of extreme impoverishment on breast and colon cancer care in Canada and the US. Ontario (N = 300) and California (N = 1,500, multiple "controls") enhanced registry-based random samples diagnosed between 2000 and 2003 were followed until 2008. Extremely poor neighborhoods (40% or more poor based on federal criteria) were compared with extremely affluent neighborhoods (< 5% poor) within-country and with similarly extremely poor neighborhoods between-country. Extreme poverty was very strongly associated with non-localized disease at diagnosis, long waits for surgery and adjuvant therapy, non-receipt of breast conserving surgery, radiation therapy (RT) and chemotherapy therapy (CT), and much shorter survival rates in California, but not in Ontario. Extremely poor people with breast and colon cancer in Ontario were largely advantaged on care as compared with their California counterparts. The relative risks of not receiving indicated RT or CT and of not surviving for at least five years after being diagnosed ranged from nearly three- to more than four-fold greater among extremely poor patients in California than among their counterparts in Ontario. Such much greater risks of substandard American cancer care among the extremely poor as compared with those previously observed among the near poor to poor suggest a dose-response relationship. More inclusive health insurance coverage in Canada seems the most plausible explanation.

Learning Areas:
Advocacy for health and health education
Provision of health care to the public
Public health or related public policy
Public health or related research
Social and behavioral sciences

Learning Objectives:
Describe the strong associations of extreme poverty with cancer treatment inaccessibility and very low cancer survival rates in America. Describe the large surgical and adjuvant therapy access and survival advantages experienced by extremely poor Canadians with cancer. Discuss the much more equitable cancer care observed in Canada in light of its most probable explanation--Canada's single payer, universally accessible health care system.

Keywords: Access to Health Care, Health Care Reform

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I have a doctorate in epidemiology from an accredited school of public health. And I have 17 years of funded research experience in social epidemiology/international comparative health services research, the results of which have been published in 90 peer-reviewed scientific journal articles.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.