Journal of Cancer Survivorship

, Volume 12, Issue 3, pp 407–416 | Cite as

The continuum of breast cancer care and outcomes in the U.S. Military Health System: an analysis by benefit type and care source

  • Yvonne L. Eaglehouse
  • Stephanie Shao
  • Wenyaw Chan
  • Derek Brown
  • Janna Manjelievskaia
  • Craig D. Shriver
  • Kangmin Zhu



This study investigates transition rates between breast cancer diagnosis, recurrence, and death by insurance benefit type and care source in U.S. Military Health System (MHS).


The MHS data repository and central cancer registry linked data were used to identify women aged 40–64 with histologically confirmed breast cancer between 2003 and 2007. Three-state continuous time Markov models were used to estimate transition rates and transition rate ratios (TRRs) by TRICARE benefit type (Prime or non-Prime) and care source (direct, purchased, or both), adjusted for demographic, tumor, and treatment variables.


Analyses included 2668 women with transitions from diagnosis to recurrence (n = 832), recurrence to death (n = 79), and diagnosis to death without recurrence (n = 91). Compared to women with Prime within each care source, women with non-Prime using both care sources had higher transition rates (TRR 1.47, 95% CI 1.03, 2.10). Compared to those using direct care within each benefit type, women utilizing both care sources with non-Prime had higher transition rates (TRR 1.86, 95% CI 1.11, 3.13), while women with Prime utilizing purchased care had lower transition rates (TRR 0.82, 95% CI 0.68, 0.98).


In the MHS, women with non-Prime benefit plans compared to Prime had higher transition rates along the breast cancer continuum among both care source users. Purchased care users had lower transition rates than direct care users among Prime beneficiaries.

Implications for Cancer Survivors

Benefit plan and care source may be associated with breast cancer progression. Further research is needed to demonstrate differences in survivorship.


Health services Breast cancer Insurance Recurrence Survival 



This project was supported by the John P. Murtha Cancer Center, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center under the auspices of the Henry M. Jackson Foundation for the Advancement of Military Medicine. The original data linkage was supported by the former United States Military Cancer Institute and Division of Cancer Epidemiology and Genetics, National Cancer Institute. The authors thank the following institutes for their contributions to the original data linkage project: ICF Macro, Kennel and Associates, Inc., the Defense Health Agency, the Joint Pathology Center and former Armed Forces Institute of Pathology, and the National Cancer Institute.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, assertions, opinions, or policies of the Uniformed Services University of the Health Sciences (USUHS), the Department of Defense (DoD), or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government.

Supplementary material

11764_2018_680_MOESM1_ESM.pdf (269 kb)
ESM 1 (PDF 269 kb)


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Yvonne L. Eaglehouse
    • 1
    • 2
  • Stephanie Shao
    • 1
  • Wenyaw Chan
    • 3
  • Derek Brown
    • 1
  • Janna Manjelievskaia
    • 1
  • Craig D. Shriver
    • 1
    • 2
  • Kangmin Zhu
    • 1
    • 4
  1. 1.John P. Murtha Cancer CenterUniformed Services University of the Health Sciences and Walter Reed National Military Medical CenterRockvilleUSA
  2. 2.Department of SurgeryUniformed Services University of the Health SciencesBethesdaUSA
  3. 3.University of Texas Health Science Center at HoustonHoustonUSA
  4. 4.Department of Preventive Medicine and BiostatisticsUniformed Services University of the Health SciencesBethesdaUSA

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