Oesophageal cancer-specific mortality risk and public health insurance: Prospective cohort study from China

doi:10.4251/wjgo.v17.i4.103629

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Apr 15, 2025 (publication date) through Mar 25, 2025

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World Journal of Gastrointestinal Oncology

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1948-5204

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Prospective Study

World J Gastrointest Oncol. Apr 15, 2025; 17(4): 103629
Published online Apr 15, 2025. doi: 10.4251/wjgo.v17.i4.103629

Table 1 Characteristics of patients with oesophagus cancer by insurance type and out-of-pocket ratio, mean ± SD/n (%)

Variables	All (n = 2543)	By insurance type			By out-of-pocket ratio
Variables	All (n = 2543)	URBMI (n = 1871)	UEBMI (n = 672)	P value	≤ 60% (n = 1450)	> 60% (n = 1093)	P value
Age	65.46 ± 8.57	65.50 ± 8.21	65.36 ± 9.50	0.703	65.50 ± 9.07	65.41 ± 7.86	0.787
Sex				< 0.001			< 0.001
Male	2088 (82.11)	1465 (78.30)	623 (92.71)		1246 (85.93)	842 (77.04)
Female	455 (17.89)	406 (21.70)	49 (7.29)		204 (14.07)	251 (22.96)
Marriage				0.245			0.498
Married	2381 (93.63)	1745 (93.27)	636 (94.64)		1353 (93.31)	1028 (94.05)
Others	162 (6.37)	126 (6.73)	36 (5.36)		97 (6.69)	65 (5.95)
Nation				1.000			1.000
Han	2519 (99.06)	1853 (99.04)	666 (99.11)		1436 (99.03)	1083 (99.09)
Other minority	24 (0.94)	18 (0.96)	6 (0.89)		14 (0.97)	10 (0.91)
BMI				< 0.001			0.003
18.5-23.9	1550 (60.95)	1181 (63.12)	369 (54.91)		856 (59.03)	694 (63.49)
≥ 24	594 (23.36)	424 (22.66)	170 (25.30)		336 (23.17)	258 (23.60)
< 18.5	399 (15.69)	266 (14.22)	133 (19.79)		258 (17.79)	141 (12.90)
KPS	83.68 ± 8.10	83.90 ± 7.74	83.06 ± 9.02	0.020	82.94 ± 8.44	84.66 ± 7.53	< 0.001
Base disease				< 0.001			< 0.001
No	2033 (79.94)	1567 (83.75)	466 (69.35)		1109 (76.48)	924 (84.54)
Yes	510 (20.06)	304 (16.25)	206 (30.65)		341 (23.52)	169 (15.46)
Pathological				0.297			0.365
Squamous cell carcinoma	2453 (96.46)	1800 (96.21)	653 (97.17)		1394 (96.14)	1059 (96.89)
Others	90 (3.54)	71 (3.79)	19 (2.83)		56 (3.86)	34 (3.11)
TNM				< 0.001			< 0.001
I	196 (7.71)	156 (8.34)	40 (5.95)		66 (4.55)	130 (11.89)
II	634 (24.93)	492 (26.30)	142 (21.13)		324 (22.34)	310 (28.36)
III	989 (38.89)	734 (39.23)	255 (37.95)		584 (40.28)	405 (37.05)
IV	724 (28.47)	489 (26.14)	235 (34.97)		476 (32.83)	248 (22.69)
Radiotherapy				< 0.001			< 0.001
No	1554 (61.11)	1214 (64.89)	340 (50.60)		627 (43.24)	927 (84.81)
Yes	989 (38.89)	657 (35.11)	332 (49.40)		823 (56.76)	166 (15.19)
Chemotherapy				0.002			< 0.001
No	1488 (58.51)	1129 (60.34)	359 (53.42)		712 (49.10)	776 (71.00)
Yes	1055 (41.49)	742 (39.66)	313 (46.58)		738 (50.90)	317 (29.00)
Surgery				0.732			< 0.001
No	1365 (53.68)	1000 (53.45)	365 (54.32)		852 (58.76)	513 (46.94)
Yes	1178 (46.32)	871 (46.55)	307 (45.68)		598 (41.24)	580 (53.06)
Immunotherapy				0.000			0.027
No	2332 (91.70)	1740 (93.00)	592 (88.10)		1314 (90.62)	1018 (93.14)
Yes	211 (8.30)	131 (7.00)	80 (11.90)		136 (9.38)	75 (6.86)
Targeted				< 0.001			< 0.001
No	2450 (96.34)	1827 (97.65)	623 (92.71)		1372 (94.62)	1078 (98.63)
Yes	93 (3.66)	44 (2.35)	49 (7.29)		78 (5.38)	15 (1.37)
FIB				< 0.001			0.006
≤ 3.66	1635 (64.29)	1265 (67.61)	370 (55.06)		899 (62.00)	736 (67.34)
> 3.66	908 (35.71)	606 (32.39)	302 (44.94)		551 (38.00)	357 (32.66)
β2 microglobulin				0.000			0.032
≤ 3.62	2246 (88.32)	1679 (89.74)	567 (84.38)		1263 (87.10)	983 (89.94)
> 3.62	297 (11.68)	192 (10.26)	105 (15.62)		187 (12.90)	110 (10.06)
LDH				0.260			0.280
≤ 236.4	2228 (87.61)	1648 (88.08)	580 (86.31)		1261 (86.97)	967 (88.47)
> 236.4	315 (12.39)	223 (11.92)	92 (13.69)		189 (13.03)	126 (11.53)
PLR				0.022			0.024
≤ 222.22	2082 (81.87)	1552 (82.95)	530 (78.87)		1165 (80.34)	917 (83.90)
> 222.22	461 (18.13)	319 (17.05)	142 (21.13)		285 (19.66)	176 (16.10)
LMR				< 0.001			< 0.001
≤ 3.18	1181 (46.44)	812 (43.40)	369 (54.91)		718 (49.52)	463 (42.36)
> 3.18	1362 (53.56)	1059 (56.60)	303 (45.09)		732 (50.48)	630 (57.64)
NLR				< 0.001			< 0.001
≤ 5.28	2178 (85.65)	1647 (88.03)	531 (79.02)		1201 (82.83)	977 (89.39)
> 5.28	365 (14.35)	224 (11.97)	141 (20.98)		249 (17.17)	116 (10.61)
ALB/GLB				0.006			0.171
≤ 1.08	436 (17.15)	297 (15.87)	139 (20.68)		262 (18.07)	174 (15.92)
> 1.08	2107 (82.85)	1574 (84.13)	533 (79.32)		1188 (81.93)	919 (84.08)
CD4/CD8				0.394			< 0.001
≤ 1.78	1484 (58.36)	1082 (57.83)	402 (59.82)		899 (62.00)	585 (53.52)
> 1.78	1059 (41.64)	789 (42.17)	270 (40.18)		551 (38.00)	508 (46.48)

URBMI: Urban and rural resident basic medical insurance; UEBMI: Urban employee basic medical insurance; BMI: Body mass index; KPS: Karnofsky performance status; TNM: Tumor-node-metastasis; FIB: Fibrinogen; LDH: Lactate dehydrogenase; PLR: Platelet-lymphocyte ratio; LMR: Lymphocyte-monocyte ratio; NLR: Neutrophil-lymphocyte ratio; ALB: Albumin; GLB: Globulin; CD: Cluster of differentiation.

Table 2 The relationship between treatment style and insurance type and out-of-pocket ratio

Variables	n (%)	¹Model A		²Model B		³Model C
Variables	n (%)	OR (95%CI)	P value	OR (95%CI)	P value	OR (95%CI)	P value
Radiotherapy
Insurance type
URBMI	657 (35.11)	1		1		1
UEBMI	332 (49.4)	1.874 (1.561-2.25)	< 0.001	1.823 (1.509-2.203)	< 0.001	1.949 (1.606-2.365)	< 0.001
Out-of-pocket ratio
≤ 60%	823 (56.76)	1		1		1
> 60%	166 (15.19)	0.124 (0.101-0.152)	< 0.001	0.124 (0.101-0.152)	< 0.001	0.118 (0.096-0.146)	< 0.001
Chemotherapy
Insurance type
URBMI	131 (7.00)	1		1		1
UEBMI	80 (11.90)	1.375 (1.139-1.659)	0.001	1.283 (1.052-1.566)	0.014	1.333 (1.089-1.632)	0.005
Out-of-pocket ratio
≤ 60%	136 (9.38)	1		1		1
> 60%	75 (6.86)	0.351 (0.294-0.418)	< 0.001	0.363 (0.302-0.437)	< 0.001	0.351 (0.291-0.423)	< 0.001
Surgery
Insurance type
URBMI	742 (39.66)	1		1		1
UEBMI	313 (46.58)	0.977 (0.813-1.173)	0.800	1.075 (0.881-1.312)	0.478	1.106 (0.904-1.354)	0.329
Out-of-pocket ratio
≤ 60%	738 (50.9)	1		1		1
> 60%	317 (29)	1.599 (1.36-1.88)	< 0.001	1.351 (1.134-1.609)	0.001	1.344 (1.126-1.603)	0.001
Immunotherapy
Insurance type
URBMI	871 (46.55)	1		1		1
UEBMI	307 (45.68)	1.889 (1.396-2.556)	< 0.001	1.763 (1.292-2.406)	< 0.001	1.755 (1.281-2.403)	< 0.001
Out-of-pocket ratio
≤ 60%	598 (41.24)	1		1		1
> 60%	580 (53.06)	0.683 (0.507-0.92)	0.012	0.729 (0.538-0.989)	0.042	0.699 (0.514-0.951)	0.023
Targeted
Insurance type
URBMI	131 (7)	1		1		1
UEBMI	80 (11.9)	3.702 (2.393-5.727)	< 0.001	3.525 (2.253-5.515)	< 0.001	3.857 (2.443-6.089)	< 0.001
Out-of-pocket ratio
≤ 60%	136 (9.38)	1		1		1
> 60%	75 (6.86)	0.224 (0.127-0.394)	< 0.001	0.229 (0.129-0.407)	< 0.001	0.215 (0.12-0.385)	< 0.001

¹Model A: We adjusted for demographic factors, including age, sex, marriage, nation, body mass index.

²Model B: Based on model A, we also adjusted for clinical characteristics, including Karnofsky performance status, base disease, pathological, tumor-node-metastasis.

³Model C: Based on model B, we additionally adjusted for blood index, including fibrinogen, β2 micro-globulin, lactate dehydrogenase, platelet-lymphocyte ratio, lymphocyte-monocyte ratio, neutrophil-lymphocyte ratio, albumin/globulin, cluster of differentiation 4/cluster of differentiation 8.

OR: Odds ratio; CI: Confidence interval; URBMI: Urban and rural resident basic medical insurance; UEBMI: Urban employee basic medical insurance.

Table 3 Association of insurance type and out-of-pocket rates with risk of cancer specific and all-cause mortality

Variables	Patients (n)	Events (n)	Rate	¹Model A		²Model B		³Model C
Variables	Patients (n)	Events (n)	Rate	HR (95%CI)	P value	HR (95%CI)	P value	HR (95%CI)	P value
Overall mortality
Insurance type	2543	1438	13.46
URBMI	1871	1012	13.24	1		1		1
UEBMI	672	426	17.43	1.199 (1.066-1.348)	0.002	1.29 (1.145-1.453)	< 0.001	1.233 (1.093-1.391)	0.001
Out-of-pocket ratio
≤ 60%	1450	924	17.50	1		1		1
> 60%	1093	514	10.13	0.85 (0.761-0.95)	0.004	0.715 (0.632-0.809)	< 0.001	0.742 (0.655-0.84)	< 0.001
Cancer-specific mortality
Insurance type	2543	1106	8.64
URBMI	1871	776	8.63	1		1		1
UEBMI	672	330	10.74	1.218 (1.066-1.392)	0.004	1.285 (1.122-1.472)	< 0.001	1.223 (1.066-1.402)	0.004
Out-of-pocket ratio
≤ 60%	1450	741	11.74	1		1		1
> 60%	1093	365	6.01	0.747 (0.657-0.850)	< 0.001	0.649 (0.562-0.748)	< 0.001	0.668 (0.579-0.772)	< 0.001

¹Model A: We adjusted for demographic factors, including age, sex, marriage, nation, body mass index, Karnofsky performance status, base disease, pathological, tumor-node-metastasis.

²Model B: Based on model A, we additionally adjusted for treatment types, including radiotherapy, chemotherapy, surgery, immunotherapy, targeted.

HR: Hazard ratio; CI: Confidence interval; URBMI: Urban and rural resident basic medical insurance; UEBMI: Urban employee basic medical insurance.

Table 4 Association of every 10% insurance out-of-pocket ratio increase with esophagus cancer-specific death and all-cause death

Variables	Patients (n)	Events (n)	Rate	¹Model A		²Model B		³Model C
Variables	Patients (n)	Events (n)	Rate	HR (95%CI)	P value	HR (95%CI)	P value	HR (95%CI)	P value
Overall mortality
Any type per 10% increase	2543	1438	13.46	0.972 (0.945-0.999)	0.045	0.943 (0.916-0.972)	< 0.001	0.955 (0.927-0.984)	0.002
Within URBMI per 10% increase	1871	1012	13.24	1.029 (0.988-1.071)	0.173	0.984 (0.941-1.029)	0.483	0.988 (0.945-1.034)	0.608
Within UEBMI per 10% increase	672	426	17.43	0.893 (0.832-0.958)	0.002	0.902 (0.838-0.971)	0.006	0.916 (0.849-0.988)	0.023
Within ≤ 60% per 10% increase	1450	924	17.50	0.958 (0.912-1.006)	0.084	0.97 (0.923-1.02)	0.239	0.986 (0.937-1.037)	0.579
Within > 60% per 10% increase	1093	514	10.13	1.294 (1.151-1.456)	< 0.001	1.174 (1.029-1.338)	0.017	1.174 (1.026-1.342)	0.020
Cancer-specify mortality
Any type per 10% increase	2543	1106	8.64	0.955 (0.925-0.985)	0.004	0.936 (0.905-0.968)	< 0.001	0.947 (0.915-0.980)	0.002
Within URBMI per 10% increase	1871	776	8.63	1.001 (0.955-1.048)	0.982	0.982 (0.932-1.034)	0.486	0.984 (0.934-1.036)	0.533
Within UEBMI per 10% increase	672	330	10.74	0.877 (0.808-0.951)	0.002	0.890 (0.818-0.969)	0.007	0.899 (0.825-0.981)	0.016
Within ≤ 60% per 10% increase	1450	741	11.74	0.976 (0.923-1.031)	0.381	0.992 (0.938-1.049)	0.776	1.010 (0.954-1.068)	0.742
Within > 60% per 10% increase	1093	365	6.01	1.380 (1.205-1.581)	< 0.001	1.273 (1.095-1.48)	0.002	1.269 (1.087-1.481)	0.003

¹Model A: We adjusted for demographic factors, including age, sex, marriage, nation, body mass index, Karnofsky performance status, base disease, pathological, tumor-node-metastasis.

²Model B: Based on model A, we additionally adjusted for treatment types, including radiotherapy, chemotherapy, surgery, immunotherapy, targeted.

HR: Hazard ratio; CI: Confidence interval; URBMI: Urban and rural resident basic medical insurance; UEBMI: Urban employee basic medical insurance.

Citation: Wu XL, Li XS, Cheng JH, Deng LX, Hu ZH, Qi J, Lei HK. Oesophageal cancer-specific mortality risk and public health insurance: Prospective cohort study from China. World J Gastrointest Oncol 2025; 17(4): 103629
URL: https://www.wjgnet.com/1948-5204/full/v17/i4/103629.htm
DOI: https://dx.doi.org/10.4251/wjgo.v17.i4.103629