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The availability of health care resources explains some geographic variation in cancer treatment:
Women with breast cancer were more likely to get breast conserving surgery (BCS) than other types of surgery if they resided in counties with a cancer center or in a large city (Samet et al., 1994).
Women were more likely to receive BCS when they were treated in hospitals with a high volume of breast cancer cases, a medical school affiliation, radiation facilities, and geriatric services (Nattinger et al., 1992).
In two studies, women with early breast cancer, who were cared for in teaching hospitals, were more likely to receive BCS than those seen in nonteaching settings (Lee-Feldstein et al., 1994; Studnicki et al., 1993).
Having health insurance and the type of coverage one has are also associated with differential treatment patterns:
Among individuals with non-small-cell lung cancer, patients without private insurance receive surgery less often than those with it (Greenberg et al., 1988).
Rates of bone marrow transplantation for leukemia or lymphoma have been from one-third to one-half lower among self-pay and Medicaid patients than among privately insured patients (Mitchell et al., 1997).
Physicians may not recommend expensive chemotherapy for uninsured or underinsured patients for financial reasons or because they believe that such groups are less likely to comply with the treatment regimen (Begg and Carbone, 1983).
In one study, one-third or more patients undergoing treatment for cancer in Texas reported out-of-pocket costs exceeding $100 per visit for chemotherapy or radiotherapy. Hispanics were more likely than whites or blacks to have out-of-pocket costs higher than $200 per visit, probably because they were uninsured or underinsured (Guidry et al., 1998).
These same investigators found that black and Hispanic cancer patients being treated in Texas with chemotherapy or radiotherapy consistently reported that barriers such as distance, access to an automobile, and availability of someone to drive them to the treatment center were major problems (Guidry et al., 1997).
The major barriers influencing whether or not patients with cancer seek or continue treatment identified in a recent review of the literature include (Guidry et al., 1996):
communication problems between patients and providers,
lack of information about side effects,
cost of treatment,
difficulties in obtaining and maintaining insurance coverage, and
absence of social support networks.
Access barriers generally were found to be greater for older women, members of minority groups, and patients of lower socioeconomic status.