Effect of Medicaid expansion on cancer treatment and survival among Medicaid beneficiaries and the uninsured.

BACKGROUND: The Affordable Care Act expanded Medicaid coverage for people with low income in the United States. Expanded insurance coverage could promote more timely access to cancer treatment, which could improve overall survival (OS), yet the long-term effects of Medicaid expansion (ME) remain unknown. We evaluated whether ME was associated with improved timely treatment initiation (TTI) and 3-year OS among patients with breast, cervical, colon, and lung cancers who were affected by the policy. METHODS: Medicaid-insured or uninsured patients aged 40-64 with stage I-III breast, cervical, colon, or non-small cell lung cancer within the National Cancer Database (NCDB). A difference-in-differences (DID) approach was used to compare changes in TTI (within 60 days) and 3-year OS between patients in ME states versus nonexpansion (NE) states before (2010-2013) and after (2015-2018) ME. Adjusted DID estimates for TTI and 3-year OS were calculated using multivariable linear regression and Cox proportional hazards regression models, respectively. RESULTS: ME was associated with a relative increase in TTI within 60 days for breast (DID = 4.6; p < 0.001), cervical (DID = 5.0 p = 0.013), and colon (DID = 4.0, p = 0.008), but not lung cancer (p = 0.505). In Cox regression analysis, ME was associated with improved 3-year OS for breast (DID hazard ratio [HR] = 0.82, p = 0.009), cervical (DID-HR = 0.81, p = 0.048), and lung (DID-HR = 0.87, p = 0.003). Changes in 3-year OS for colon cancer were not statistically different between ME and NE states (DID-HR, 0.77; p = 0.075). CONCLUSIONS: Findings suggest that expanded insurance coverage can improve treatment and survival outcomes among low income and uninsured patients with cancer. As the debate surrounding ME continues nationwide, our findings serve as valuable insights to inform the development of policies aimed at fostering accessible and affordable healthcare for all.

Who, where, when: Colorectal cancer disparities by race and ethnicity, subsite, and stage.

BACKGROUND: There are well-established disparities in colorectal cancer (CRC) outcomes between White and Black patients; however, assessments of CRC disparities for other racial/ethnic groups are limited. METHODS: The Surveillance, Epidemiology, and End Results database identified patients aged 50-74 years with CRC adenocarcinoma from 2000 to 2019. Trends in age-adjusted incidence rates were computed by stage at diagnosis and subsite across five broad race/ethnic groups (White, Black, Asian/Pacific Islander [API], American Indian/Alaskan Native [AIAN], and Hispanic) and four API subgroups (East Asian, Southeast Asian, South Asian, and Pacific Islander) Multivariable logistic regression evaluated associations between race/ethnicity and diagnosis stage. Multivariable Cox proportional hazards models assessed differences in cause-specific survival (CSS). RESULTS: Hispanic, AIAN, Southeast Asian, Pacific Islander, and Black patients were 3% to 28% more likely than Whites to be diagnosed with distant stage CRC, whereas East Asian and South Asians had similar or lower risk of distant stage CRC. From Cox regression analysis, Black, AIAN, and Pacific Islanders also experienced worse CSS, while East Asian and South Asian patient groups experienced better CSS. No significant differences in CSS were observed among Hispanic, Southeast Asian, and White patients. When stratified by stage, Black patients had worse CSS across all stages (early, hazard ratio (HR) = 1.38; regional, HR = 1.22; distant, HR: 1.07, p < 0.05 for all). CONCLUSION: Despite advances in CRC screening, treatment and early detection efforts, marked racial/ethnic disparities in incidence, stage at diagnosis, and survival persist. Findings demonstrate the extent to which aggregating heterogenous populations masks significant variability in CRC outcomes within race/ethnic subgroups.

Medicaid Expansion and Postoperative Mortality in Women with Gynecologic Cancer: A Difference-in-Difference Analysis.

BACKGROUND: The association between Medicaid expansion and postoperative mortality after surgery for gynecologic cancer is unknown. Our objective was to compare 30- and 90-day postoperative mortality after gynecologic cancer surgery before and after 2014 in states that did and did not expand Medicaid. METHODS: We searched the National Cancer Database for women aged 40-64 years old between 2010 and 2016 who underwent surgery for a primary gynecologic malignancy. We used pre/post and quasi-experimental difference-in-difference (DID) multivariable logistic regressions to evaluate mortality pre-2014 (2010-2013) and post-2014 (2014-2016) for states that did and did not expand Medicaid in January 2014. We completed univariable logistic regressions for covariates of interest. RESULTS: Among 169,731 women, 30-day postoperative mortality in expansion states after 2014 significantly decreased for endometrial cancer (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.26-0.67) and ovarian cancer (OR 0.67, 95% CI 0.46-0.99) and increased for cervical cancer (OR 3.82, 95% CI 1.12-13.01). Compared with non-expansion states, expansion states had improved 30-day postoperative mortality for endometrial cancer after 2014 (DID OR 0.54, 95% CI 0.31-0.96). Univariable analysis demonstrated improved 30-day postoperative mortality for Black women with endometrial cancer in expansion states (DID OR 0.22, 95% CI 0.05-0.95). There was improved 90-day postoperative mortality for endometrial cancer in expansion states (OR 0.66, 95% CI 0.50-0.85), and improved 90-day postoperative mortality for Midwestern women with ovarian cancer in expansion states on univariable analysis (DID OR 0.48, 95% CI 0.26-0.91). CONCLUSIONS: State Medicaid legislation was associated with improved postoperative survival in women with endometrial cancer and subgroups of women with endometrial and ovarian cancer.

Association between time to diagnosis, time to treatment, and ovarian cancer survival in the United States.

OBJECTIVE: Evaluate the association between time to diagnosis and treatment of advanced ovarian cancer with overall and ovarian cancer specific mortality using a retrospective cross sectional study of a population based cancer registry database. METHODS: The Surveillance, Epidemiology, and End Results-Medicare database was searched from 1992 to 2015 for women aged ≥66 years with epithelial ovarian cancer and abdominal/pelvic pain, bloating, difficulty eating, or urinary symptoms within 1 year of cancer diagnosis. Time from presentation to diagnosis and treatment were evaluated as outcomes and covariables. Cox regression models and adjusted Kaplan-Meier curves evaluated 5 year overall and cancer-specific survival. RESULTS: Among 13 872 women, better survival was associated with longer time from presentation to diagnosis (overall survival hazard ratio (HR) 0.95, 95% confidence interval (CI) 0.94 to 0.95; cancer specific survival HR 0.95, 95% CI 0.94 to 0.96) and diagnosis to treatment (overall survival HR 0.94, 95% CI 0.92 to 0.96; cancer specific survival HR 0.93, 95% CI 0.91 to 0.96). There was longer time from presentation to diagnosis in Hispanic women (relative risk (RR) 1.21, 95% CI 1.12 to 1.32) and from diagnosis to treatment in non-Hispanic black women (RR 1.36, 95% CI 1.21 to 1.54), with lower likelihood of survival at 5 years after adjustment for time to diagnosis and treatment among non-Hispanic black women (HR 1.15, 95% CI 1.05 to 1.26) compared with non-Hispanic white women. Gynecologic oncology visit was associated with improved overall (p<0.001) and cancer specific (p<0.001) survival despite a longer time from presentation to treatment (p<0.001). CONCLUSION: Longer time to diagnosis and treatment were associated with improved survival, suggesting that tumor specific features are more important prognostic factors than the time interval of workup and treatment. Significant sociodemographic disparities indicate social determinants of health influencing workup and care. Gynecologic oncologist visits were associated with improved survival, highlighting the importance of appropriate referral for suspected ovarian cancer.

Racial and Ethnic Trends and Disparities in NSCLC.

Introduction: Detailed evaluations of racial and ethnic trends and disparities in NSCLC outcomes are lacking, and it remains unclear whether recent advances in screening and targeted therapies for NSCLC have benefited all population groups equally. Methods: Using the Surveillance, Epidemiology, and End Results 18-registry data, we evaluated trends in overall and stage-specific NSCLC incidence (2007-2018) among patients aged 55 to 79 years by sex and race and ethnicity. Overall and stage-specific 2-year cause-specific survival rates were calculated by sex and race and ethnicity. Health Disparities software calculated absolute (difference) and relative (ratio) disparity measures comparing racial and ethnic groups with the highest and lowest rates (range measures) and comparing white patients (reference group) with other groups (pairwise rate measures). Joinpoint software assessed changes in rates and disparities. Results: Both men and women experienced substantial declines in NSCLC incidence from 2007 to 2018, largely due to significant declines in the incidence of distant-stage NSCLC over the study period (p < 0.05). During the same time period, the incidence of local-stage NSCLC significantly increased among black and Hispanic women (p < 0.05) and remained stable among all other groups. Overall, 2-year cause-specific survival rates improved across most racial and ethnic groups, especially among those diagnosed in regional and distant stages. For both sexes, absolute disparities in overall and stage-specific incidence of NSCLC significantly decreased over time (p < 0.05), whereas relative disparities remained unchanged. Pairwise comparison revealed persistent disparities in NSCLC burden between black and white men. Conclusion: We found evidence of narrowing racial and ethnic disparities in NSCLC incidence over time; however, important disparities persist. More work is needed to ensure consistent and equitable access to high-quality screening, diagnosis, and treatment to reduce and eliminate cancer disparities.

Impacts of Medicaid Expansion on Stage at Cancer Diagnosis by Patient Insurance Type.

INTRODUCTION: The expansion of Medicaid under the Affordable Care Act increased access to health care for millions of low-income Americans. However, the longer-term impacts of the policy on cancer outcomes remain unknown. This study examined the impact of Medicaid expansion on early- and late-stage diagnosis for 4 common cancers (breast, cervical, colorectal, and lung) using 4 full years of postpolicy data. METHODS: Patients aged 40-64 years diagnosed with breast, cervical, colorectal, or lung cancer from 2010 to 2017 were identified using the National Cancer Database. Difference-in-difference analyses compared changes in early-stage and late-stage diagnoses among expansion states with those among nonexpansion states. Subgroup analyses explored potential effect modification by insurance type. Data analysis was performed from June to October 2021. RESULTS: The proportion of early stage diagnosis of breast (difference in difference=1.58, 95% CI=0.89, 2.27), cervical (difference in difference=3.20; 95% CI=0.44, 5.95), colorectal (difference in difference=1.98; 95% CI=1.18, 2.78), and lung (difference in difference=1.74; 95% CI=0.98, 2.50) cancers increased more in expansion states than in nonexpansion states, whereas late-stage diagnosis of colorectal (difference in difference= -2.12; 95% CI= -2.98, -1.27) and lung (difference in difference= -1.87; 95% CI= -2.89, -0.84) cancers decreased more in expansion states following implementation of the Affordable Care Act. In subgroup analyses, difference-in-difference estimates for all sites and stages (except late-stage cervical cancer) were significant and larger in magnitude among Medicaid-insured than among privately insured patients. CONCLUSIONS: Study results highlight the positive impacts of Medicaid expansion on earlier diagnosis of several cancers for which screening and early detection exist, and subgroup analyses revealed greater positive effects among Medicaid-insured patients most targeted by the policy.

Navigating financial toxicity in patients with cancer: A multidisciplinary management approach.

Approximately one-half of individuals with cancer face personal economic burdens associated with the disease and its treatment, a problem known as financial toxicity (FT). FT more frequently affects socioeconomically vulnerable individuals and leads to subsequent adverse economic and health outcomes. Whereas multilevel systemic factors at the policy, payer, and provider levels drive FT, there are also accompanying intervenable patient-level factors that exacerbate FT in the setting of clinical care delivery. The primary strategy to intervene on FT at the patient level is financial navigation. Financial navigation uses comprehensive assessment of patients' risk factors for FT, guidance toward support resources, and referrals to assist patient financial needs during cancer care. Social workers or nurse navigators most frequently lead financial navigation. Oncologists and clinical provider teams are multidisciplinary partners who can support optimal FT management in the context of their clinical roles. Oncologists and clinical provider teams can proactively assess patient concerns about the financial hardship and employment effects of disease and treatment. They can respond by streamlining clinical treatment and care delivery planning and incorporating FT concerns into comprehensive goals of care discussions and coordinated symptom and psychosocial care. By understanding how age and life stage, socioeconomic, and cultural factors modify FT trajectory, oncologists and multidisciplinary health care teams can be engaged and informative in patient-centered, tailored FT management. The case presentations in this report provide a practical context to summarize authors' recommendations for patient-level FT management, supported by a review of key supporting evidence and a discussion of challenges to mitigating FT in oncology care. CA Cancer J Clin. 2022;72:437-453.

Medicaid expansion and 2-year survival in women with gynecologic cancer: a difference-in-difference analysis.

BACKGROUND: The Affordable Care Act implemented optional Medicaid expansion starting in 2014, but the association between Medicaid expansion and gynecologic cancer survival is unknown. OBJECTIVE: To evaluate the impact of Medicaid expansion by comparing 2-year survival among gynecologic cancers before and after 2014 in states that did and did not expand Medicaid using a difference-in-difference analysis. STUDY DESIGN: We searched the National Cancer Database for women aged 40 to 64 years, diagnosed with a primary gynecologic malignancy (endometrial, ovarian, cervical, vulvar, and vaginal) between 2010 and 2016. We used a quasiexperimental difference-in-difference multivariable Cox regression analysis to compare 2-year survival between states that expanded Medicaid in January 2014 and states that did not expand Medicaid as of 2016. We performed univariable subgroup difference-in-difference Cox regression analyses on the basis of stage, income, race, ethnicity, and geographic location. Adjusted linear difference-in-difference regressions evaluated the proportion of uninsured patients on the basis of expansion status after 2014. We evaluated adjusted Kaplan-Meier curves to examine differences on the basis of study period and expansion status. RESULTS: Our sample included 169,731 women, including 78,669 (46.3%) in expansion states and 91,062 (53.7%) in nonexpansion states. There was improved 2-year survival on adjusted difference-in-difference Cox regressions for women with ovarian cancer in expansion than in nonexpansion states after 2014 (hazard ratio, 0.88; 95% confidence interval, 0.82-0.94; P<.001) with no differences in endometrial, cervical, vaginal, vulvar, or combined gynecologic cancer sites on the basis of expansion status. On univariable subgroup difference-in-difference Cox analyses, women with ovarian cancer with stage III-IV disease (P=.008), non-Hispanic ethnicity (P=.042), those in the South (P=.016), and women with vulvar cancer in the Northeast (P=.022), had improved 2-year survival in expansion than in nonexpansion states after 2014. In contrast, women with cervical cancer in the South (P=.018) had worse 2-year survival in expansion than in nonexpansion states after 2014. All cancer sites had lower proportions of uninsured patients in expansion than in nonexpansion states after 2014. CONCLUSION: There was a significant association between Medicaid expansion and improved 2-year survival for women with ovarian cancer in states that expanded Medicaid after 2014. Despite improved insurance coverage, racial, ethnic, and regional survival differences exist between expansion and nonexpansion states.

A Contemporary Analysis of Racial and Ethnic Disparities in Diagnosis of Early-Stage Breast Cancer and Stage-Specific Survival by Molecular Subtype.

BACKGROUND: Prior studies of breast cancer disparities have focused primarily on differences between Black and White women, yet contemporary patterns of disparity for other groups are not well understood. We examine breast cancer disparities by stage at diagnosis across nine racial and ethnic groups. METHODS: The SEER 18 registries identified 841,975 women diagnosed with breast cancer from 2000 to 2017. Joinpoint models assessed trends in diagnosis stage and survival. Multivariable logistic regression evaluated associations between race/ethnicity and diagnosis stage. Multivariable Cox models compared survival of groups by stage and molecular subtype. RESULTS: Black, American Indian, Southeast Asian, South Asian, Pacific Islander, and Hispanic women were less likely than white women to be diagnosed with early stage breast cancer. Among those diagnosed at early stage, Hispanic, American Indian, Pacific Islander and Black women were 9%, 14%, 22%, and 39% (respectively) more likely than White women to die from breast cancer, whereas Asian subgroups had lower risk of death. Among those diagnosed at late stage, Black women were 18% more likely than White counterparts to die from breast cancer, and survival disparities for Black women persisted across all subtypes and stages, (except late stage HR-/HER2-). East Asian women with early stage HR+/HER2- tumors had better survival than White women. CONCLUSIONS: Persistent disparities in early detection and survival of breast cancer demand further work to address and reduce disparities across the cancer continuum. IMPACT: Results have implications for efforts to reduce entrenched racial and ethnic disparities in breast cancer early detection and survival.

Temporal trends of healthcare system use between symptomatic presentation and ovarian cancer diagnosis in the United States.

OBJECTIVE: To describe trends in healthcare system use over time between onset of classic ovarian cancer symptoms and ovarian cancer diagnosis in the United States. METHODS: A population-based study of the Surveillance, Epidemiology, and End Results-Medicare database was conducted on patients aged ≥66 years with stage II-IV epithelial ovarian cancer between 1992 and 2015 with at least one of the following diagnosis codes: abdominal pain, bloating, difficulty eating, and/or urinary symptoms. The outcomes were frequency of visit type, frequency of diagnostic modality, and Medicare reimbursement between first symptomatic claim and cancer diagnosis. Jonckheere-Terpstra and Cochran-Armitage tests were used to evaluate trends over time. RESULTS: Among 13 872 women, 13 541 (97.6%) had outpatient, 6466 (46.6%) had inpatient, and 4906 (35.4%) had emergency room visits. The frequency of outpatient (p<0.001) and emergency room visits (p<0.001) increased while the frequency of inpatient visits (p<0.001) decreased between 1992 and 2015. The median number of outpatient visits (p<0.001) and physician specialties seen (p<0.001) increased over time. The median hospital length of stay decreased from 10 days in 1992 to 5 days in 2015 (p<0.001). Between 1992 and 2015, the frequency of ultrasound decreased (p<0.001) while the frequency of computed tomography, magnetic resonance imaging, positron emission tomography imaging, and cancer antigen 125 tumor immunoassay increased (p<0.001). Median monthly total (p<0.001), inpatient (p<0.001), and outpatient (p=0.006) reimbursements decreased while emergency room reimbursements increased (p<0.001) over time. CONCLUSION: Healthcare reimbursement between symptomatic presentation and ovarian cancer diagnosis has decreased over time and may reflect the trends in fewer and shorter hospitalizations and increased use of emergency and outpatient management during the evaluation of symptoms of women with ovarian cancer.

Evaluating community-driven cardiovascular health policy changes in the United States using agent-based modeling.

Comprehensive smoke-free policy is a strategy to prevent cardiovascular disease (CVD) at a population-level; however, evaluating their long-term outcomes is difficult. This study used an agent-based model to estimate long-term impacts of a comprehensive smoke-free policy, as it was implemented in two communities, Arlington and Mesquite, Texas. The model predicted the percentage of myocardial infarction (MI), stroke, and diabetes in the population 10 and 20 years following policy adoption. In Arlington, the percentage of the population with these conditions each decreased by approximately 0.5% over 20 years; in Mesquite, the percentage of the population with diabetes, myocardial infarction (MI), and stroke decreased by 1.1%, 0.6%, and 0.3%, respectively, after 20 years. The results were statistically significant (p < 0.001). As an evaluation strategy, agent-based modeling can help researchers and practitioners estimate the potential long-term effects of policies and garner intervention support for implementation.

Factors impacting the time to ovarian cancer diagnosis based on classic symptom presentation in the United States.

BACKGROUND: Patients with ovarian cancer often present with late-stage disease and nonspecific symptoms, but little is known about factors affecting the time to diagnosis (TTD) in the United States. METHODS: A retrospective, population-based study of the Surveillance, Epidemiology, and End Results-Medicare database was conducted. It included women 66 years old or older with stage II to IV epithelial ovarian cancer with at least 1 code for abdominal/pelvic pain, bloating, difficulty eating, or urinary symptoms within 1 year of the cancer diagnosis. TTD was defined from the first claim with a prespecified symptom to the ovarian cancer diagnosis. Kruskal-Wallis tests were used to assess for differences in TTD by group medians. Univariate and generalized linear models with a log-link function evaluated TTD by covariables. RESULTS: For the 13,872 women analyzed, the mean and median times to diagnosis were 2.9 and 1.1 months, respectively. The median TTD differed significantly by first symptom (P < .001), number of symptoms (P < .001), and first physician specialty seen (P < .001). In a multivariable analysis, TTD differed significantly according to race/ethnicity (P < .001), geographic region (P = .001), urban-rural location (P = .031), emergency room presentation (P < .001), and number of specialties seen (P < .001). A shorter TTD was associated with a diagnosis in 2006-2010 (relative risk [RR], 0.92; 95% confidence interval [CI], 0.87-0.98) or 2011-2015 (RR, 0.87; 95% CI, 0.81-0.93) in comparison with 1992-1999. CONCLUSIONS: The time from a symptomatic presentation to care to a diagnosis of ovarian cancer is influenced by clinical and demographic variables. This study's findings reinforce the importance of educating all physicians on ovarian cancer symptoms to aid in diagnosis. LAY SUMMARY: Ovarian cancer is often diagnosed once disease has spread because the classic symptoms of ovarian cancer-abdominal or pelvic pain, bloating, difficulty eating, and urinary issues-can be mistaken for other problems. This study examined the time between when women with classic ovarian cancer symptoms went to a physician and when they received a cancer diagnosis in a large database population. The authors found that the time to diagnosis differed according to the type and number of symptoms and what type of physician a woman saw as well as factors such as race, geographic location, and year of diagnosis.