Open Access Highly Accessed Research article

Lack of access to chemotherapy for colon cancer: multiplicative disadvantage of being extremely poor, inadequately insured and African American

Kevin M Gorey1*, Sundus Haji-Jama1, Emma Bartfay2, Isaac N Luginaah3, Frances C Wright4 and Sindu M Kanjeekal5

Author Affiliations

1 School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, Ontario N9B, 3P4, Canada

2 Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada

3 Department of Geography, University of Western Ontario, London, Ontario, Canada

4 Sunnybrook Health Sciences Center and cross appointed to the Departments of Surgery and Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

5 Windsor Regional Cancer Center, Windsor, Ontario, Canada

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BMC Health Services Research 2014, 14:133  doi:10.1186/1472-6963-14-133

Published: 22 March 2014



Despite evidence of chemotherapy’s ability to cure or comfort those with colon cancer, nearly half of such Americans do not receive it. African Americans (AA) seem particularly disadvantaged. An ethnicity by poverty by health insurance interaction was hypothesized such that the multiplicative disadvantage of being extremely poor and inadequately insured is worse for AAs than for non-Hispanic white Americans (NHWA).


California registry data were analyzed for 459 AAs and 3,001 NHWAs diagnosed with stage II to IV colon cancer between 1996 and 2000 and followed until 2011. Socioeconomic data from the 2000 census categorized neighborhoods: extremely poor (≥ 30% of households poor), middle (5-29% poor) and low poverty (< 5% poor). Participants were randomly selected from these poverty strata. Primary health insurers were Medicaid, Medicare, private or none. Chemotherapy rates were age and stage-adjusted and comparisons used standardized rate ratios (RR). Logistic and Cox regressions, respectively, modeled chemotherapy receipt and long term survival.


A significant 3-way ethnicity by poverty by health insurance interaction effect on chemotherapy receipt was observed. Among those who did not live in extremely poor neighborhoods and were adequately insured privately or by Medicare, chemotherapy rates did not differ significantly between AAs (37.7%) and NHWAs (39.5%). Among those who lived in extremely poor neighborhoods and were inadequately insured by Medicaid or uninsured, AAs (14.6%) were nearly 60% less likely to receive chemotherapy than were NHWAs (25.5%, RR = 0.41). When the 3-way interaction effect as well as the main effects of poverty, health insurance and chemotherapy was accounted for, survival rates of AAs and NHWAs were the same.


The multiplicative barrier to colon cancer care that results from being extremely poor and inadequately insured is worse for AAs than it is for NHWAs. AAs are more prevalently poor, inadequately insured, and have fewer assets so they are probably less able to absorb the indirect and direct, but uncovered, costs of colon cancer care. Policy makers ought to be cognizant of these factors as they implement the Affordable Care Act and consider future health care reforms.

Health insurance; Uninsured; Underinsured; Poverty; Colon cancer; Chemotherapy; African American; Ethnicity; Health care reform; California; United States