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American Journal of Public Health





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Adult, Aged, Breast Neoplasms/mortality, Breast Neoplasms/therapy, Confounding Factors (Epidemiology), Female, Hawaii/epidemiology, Health Benefit Plans, Employee/statistics & numerical data, Health Services Research, Humans, Income/statistics & numerical data, Insurance Coverage/statistics & numerical data, Insurance, Health/classification Insurance, Health/statistics & numerical data, Male, Middle Aged, National Health Programs/statistics & numerical data, Ontario/epidemiology, Prostatic Neoplasms/mortality, Prostatic Neoplasms/therapy, Quality of Health Care, Single-Payer System/statistics & numerical data, Socioeconomic Factors, Survival Analysis, Universal Coverage/statistics & numerical data, Urban Health/statistics & numerical data

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OBJECTIVES: Comparisons of cancer survival in Canadian and US metropolitan areas have shown consistent Canadian advantages. This study tests a health insurance hypothesis by comparing cancer survival in Toronto, Ontario, and Honolulu, Hawaii.

METHODS: Ontario and Hawaii registries provided a total of 9190 and 2895 cancer cases (breast and prostate, 1986-1990, followed until 1996). Socioeconomic data for each person's residence at the time of diagnosis were taken from population censuses.

RESULTS: Socioeconomic status and cancer survival were directly associated in the US cohort, but not in the Canadian cohort. Compared with similar patients in Honolulu, residents of low-income areas in Toronto experienced 5-year survival advantages for breast and prostate cancer. In support of the health insurance hypothesis, between-country differences were smaller than those observed with other state samples and the Canadian advantage was larger among younger women.

CONCLUSIONS: Hawaii seems to provide better cancer care than many other states, but patients in Toronto still enjoy a significant survival advantage. Although Hawaii's employer-mandated health insurance coverage seems an effective step toward providing equitable health care, even better care could be expected with a universally accessible, single-payer system.