Medicaid Expansion Increases Access for Rural and Impoverished Patients with Pancreatic Ductal Adenocarcinoma in Southern States.

INTRODUCTION: Medicaid expansion (ME) impacted patients when assessed at a national level. However, of the 32 states in which Medicaid expansion occurred, only 3 were Southern states. Whether results apply to Southern states that share similar geopolitical perspectives remains elusive. We aimed to assess the impact of ME on pancreatic ductal adenocarcinoma (PDAC) treatment in eight Southern states in the USA. PATIENTS AND METHODS: We identified uninsured or Medicaid patients (age 40-64 years) diagnosed with PDAC between 2011 and 2018 in Southern states from the North American Association of Central Cancer Registries-Cancer in North America (NAACCR-CiNA) research dataset. Medicaid-expanded states (MES; Louisiana, Kentucky, and Arkansas) were compared with non-MES (NMES; Tennessee, Alabama, Mississippi, Texas, and Oklahoma) using multivariate logistic regression. P < 0.05 was considered statistically significant. RESULTS: Among 3036 patients, MES significantly increased odds of Medicaid insurance by 36%, and increased proportions of insured Black patients by 3.7%, rural patients by 3.8%, and impoverished patients by 18.4%. After adjusting for age, race, rural-urban status, poverty status, and summary stage, the odds of receiving radiation therapy decreased by 26% for each year of expansion in expanded states (P = 0.01). Last, ME did not result in a significant difference between MES and NMES in diagnosing early stage disease (P = 0.98) nor in receipt of chemotherapy or surgery (P = 0.23 and P = 0.63, respectively). CONCLUSIONS: ME in Southern states increased insurance access to traditionally underserved groups. Interestingly, ME decreased the odds of receiving radiation therapy yearly and had no significant impact on receipt of chemotherapy or surgery.

Impact of Medicaid Expansion on Breast Cancer Diagnosis and Treatment in Southern States.

BACKGROUND: Medicaid expansion impacted patients when assessed at a national level. However, of the 32 states that expanded Medicaid, only three were Southern states. Whether results apply to Southern states that share similar geopolitical perspectives remains elusive. We aimed to assess the impact of Medicaid expansion on breast cancer diagnosis and treatment in 8 Southern states in the US. STUDY DESIGN: We identified uninsured or Medicaid patients (age 40 to 64 years) diagnosed with invasive breast cancer from 2011 to 2018 in Southern states from the North American Association of Central Cancer Registries-Cancer in North America Research Dataset. Medicaid-expanded states ([MES], Louisiana, Kentucky, Arkansas) were compared with non-MES ([NMES], Tennessee, Alabama, Mississippi, Texas, Oklahoma) using multivariate logistic regression and differences-in-differences analyses during pre- and postexpansion periods; p < 0.05 was considered statistically significant. RESULTS: Among 21,974 patients, patients in MES had increased odds of Medicaid insurance by 43% (odds ratio 1.43, p < 0.01) and decreased odds of distant-stage disease by 7% (odds ratio 0.93, p = 0.03). After Medicaid expansion, Medicaid patients increased by 10.6% in MES (Arkansas, Kentucky), in contrast to a 1.3% decrease in NMES (differences-in-differences 11.9%, p < 0. 0001, adjusting for age, race/ethnicity, rural-urban status, and poverty status). MES (Arkansas, Kentucky) had 2.3% fewer patients diagnosed with distant-stage disease compared with a 0.5% increase in NMES (differences-in-differences 2.8%, p = 0.01, after adjustment). Patients diagnosed in MES had higher odds of receiving treatment (odds ratio 2.27, p = 0.03). CONCLUSIONS: Unlike NMES, MES experienced increased Medicaid insured, increased treatment, and decreased distant-stage disease at diagnosis. Medicaid expansion in the South leads to earlier and more comprehensive treatment of breast cancer.

Distance to radiation therapy facility influences surgery type among older women with early-stage breast cancer.

BACKGROUND: Breast-conserving surgery plus radiation (BCT) yields equivalent or better survival than mastectomy for early-stage breast cancer (ESBC) women. However, nationwide mastectomy trends increased in recent decades, attracting studies on underlying causes. Prior research identified that long distance to the radiation treatment facility (RTF) was associated with mastectomy. Still, it is unclear whether such association applies to young and old ESBC women comparably. We sought to delineate such impacts by age. METHODS: Women diagnosed with stages 0-II breast cancer in 2013-2017 receiving either BCT or mastectomy were identified from the Louisiana Tumor Registry. We assessed the association of surgery (mastectomy vs. BCT) with the distance to the nearest or nearest accessible RTFs using multivariable logistic regression adjusting the socio-demographic and tumor characteristics. The nearest accessible RTF was determined based on patients' health insurance. For Medicaid, uninsured, and unknown insurance patients, the nearest accessible RTF is the nearest RTF owned by the government. The interaction effect of age and distance was evaluated as well. RESULTS: Of 11,604 patients, 46.7% received mastectomy. Compared with distance ≤5 miles to the nearest RTF, those with distance ≥40 miles or 15-40 miles had higher odds of mastectomy (adjusted (adj) OR = 1.39, 95% CI = 1.07-1.82; adj OR = 1.17, 95% CI = 1.02-1.34). To the nearest accessible RTF, the adj ORs were 1.25 (95% CI = 1.03-1.51) and 1.19 (95% CI = 1.04-1.35), respectively. Age-stratified analysis showed the significant association (p < 0.05) only presented among women aged ≥65, but not those aged <65 years. CONCLUSION: Distance to the nearest or nearest accessible RTF influences the surgery choice, especially among women in Louisiana ≥65 years with ESBC. Further understanding of factors leading to the decision for mastectomy in this age group is needed.

Treatment at a high-volume academic research program mitigates racial disparities in pancreatic adenocarcinoma.

BACKGROUND: Racial disparities have long been a subject of concern between patients afflicted with pancreatic cancer in the United States. We believe that, in addition to a high-volume center, treatment at an academic research program (ARP) will mitigate racial outcome disparities. METHODS: A total of 12,950 patients diagnosed with stage I-III pancreatic adenocarcinoma from 2003-2011 and at ACS Commission on Cancer (COC) accredited facilities [e.g., high-volume (≥12 cases/year) ARPs] were evaluated from the National Cancer Data Base (NCDB). Sociodemographic, clinicopathological, and treatment variables were compared between Black (N=1,127) and White (N=11,823) patients. The Kaplan-Meier Estimator and Cox Proportional Hazards Model were used for survival analysis. P value ≤0.05 was considered significant. RESULTS: Black patients had a significantly higher overall survival (OS) than White patients, despite having a significantly lower household income, lower education level, more stage III disease, more Medicaid recipients, and higher comorbidity index (P<0.05). The 5-year unadjusted OS (28.6% versus 23.9%, a median survival time (months) was (25.2 versus 23.7 months for Black and White patients, respectively (P<0.05). There was no significant difference in surgical margin status or receipt of chemoradiation between the two cohorts. After adjusting for covariates, race was no longer a significant predictor of OS (P=0.096). CONCLUSIONS: Treatment at a high volume, ARP can mitigate racial disparities in pancreatic cancer.

10-Year Survival after Breast-Conserving Surgery Compared with Mastectomy in Louisiana Women with Early-Stage Breast Cancer: A Population-Based Study.

BACKGROUND: Louisiana has the third highest breast cancer mortality in the US, despite ranking 30th in incidence. Whether surgical approach contributes to such a poor outcome is unknown. We compared outcomes of breast-conserving surgery plus radiation (BCT) vs mastectomy (MST) for Louisiana women with early-stage breast cancer. STUDY DESIGN: Data on women diagnosed with Stage I-II breast cancer from 2004 to 2016 were analyzed from the Louisiana Tumor Registry. Overall survival (OS) and breast cancer-specific survival (CSS) were compared between BCT and MST. Kaplan-Meier method and log-rank test were used to compare survival curves, and logistic regression was used to examine the association of sociodemographic and clinical factors with the type of breast cancer surgery. Values of p < 0.05 were considered significant. RESULTS: Of the 18,260 patients, 9,968 patients (54.6%) had BCT and 8,292 patients (45.4%) had MST. Compared with BCT, the MST group tended to be underinsured/Medicare/Medicaid, more impoverished, had higher stage 2 disease, were more likely to reside in rural regions, travel ≥25 miles to radiation treatment facility, be treated at low volume centers, and have T3, node positive, and poorly differentiated tumors. Ten-year OS and CSS were significantly better among those who had BCT (OS: 80.0%; 95% CI: 79.0%-81.1%; CSS: 92.7%; 95% CI: 92.1%-93.4%) than those having MST (OS: 69.3%; 95% CI: 68.0%-70.5%; CSS: 88.8%:95% CI: 87.9%-89.7%) (p < 0.05). Even after controlling for sociodemographic and clinical variables, MST was associated with a 28.6% increased risk of death from all causes (hazard ratio [HR]:1.286; 95% CI:1.197-1.380) and a 29.8% increased risk of breast-cancer specific death (HR:1.298; 95% CI: 1.150-1.465). CONCLUSIONS: Surgical approach, a factor that is within the control of the surgeon, has an impact on mortality for Louisiana women with early-stage breast cancer.

Positive impact of the Patient Protection and Affordable Care Act Medicaid expansion on Louisiana women with breast cancer.

BACKGROUND: Louisiana is one of the few Southern states that enacted the Medicaid expansion of the Patient Protection and Affordable Care Act (ACA). To the authors' knowledge, the issue of how this has affected the breast cancer landscape in Louisiana is unknown. The authors have postulated that ACA expansion had a positive impact for Louisiana women diagnosed with breast cancer. METHODS: Data from the Louisiana Tumor Registry regarding 14,640 women aged 20 to 64 years who resided in Louisiana and were diagnosed with American Joint Committee on Cancer stage 0 to stage IV breast cancer between 2012 and 2018 were analyzed. The study period was divided into 2 groups: 1) before ACA expansion (January 1, 2012-May 31, 2016); and 2) after ACA expansion (June 1, 2016-December 31, 2018). The chi-square test and multivariable logistic regression models were used to assess the impact of ACA expansion. A P value <.05 was considered statistically significant. RESULTS: After ACA expansion, the rate of uninsured patients decreased from 5.4% to 3.0% (P < .0001), and the rate of Medicaid recipients increased from 11.6% to 17.7% (P < .0001). The diagnosis of stage I breast cancer increased from 36.8% to 44.7% (P < .0001), whereas the diagnosis of stage III breast cancer decreased from 10.7% to 8.5% (P < .0001). The receipt of radiotherapy after breast-conserving surgery increased from 81.2% to 84.0% (P = .0035), and the receipt of radiotherapy within 90 days increased from 57.2% to 61.7% (P = .0012). After adjustment for sociodemographic and clinical variables, the models demonstrated that ACA expansion decreased the uninsured rate by 48% (odds ratio [OR], 0.52; 95% CI, 0.43-0.63), increased the diagnosis of early-stage disease (stage0 to stage II) by 27% (OR, 1.27; 95% CI, 1.15-1.41), increased receipt of radiotherapy after breast-conserving surgery by 19% (OR, 1.19; 95% CI, 1.03-1.37), and reduced the delay of receipt of radiotherapy by 16% (OR, 0.84; 95% CI, 0.74-0.95). CONCLUSIONS: ACA expansion in Louisiana reduced the uninsured rate, increased the diagnosis of early-stage disease, and increased access to treatment.

Impact of CALGB 9343 Trial and Sociodemographic Variation on Patterns of Adjuvant Radiation Therapy Practice for Elderly Women (≥70 Years) with Stage I, Estrogen Receptor-positive Breast Cancer: Analysis of the National Cancer Data Base.

BACKGROUND: The Cancer and Leukemia Group B (CALGB) 9343 trial demonstrated that adjuvant radiation therapy (RT) can be omitted in women 70 years or older, with small (≤2 cm), negative lymph nodes, estrogen receptor (ER)-positive breast cancer. We examined whether RT usage following the CALGB publication had decreased over time and evaluated sociodemographic and clinical factors associated with RT omission. MATERIALS AND METHODS: From the National Cancer Data Base, we analyzed a cohort of 120,308 women aged 70 years or older with stage I, ER-positive breast cancer who underwent lumpectomy. Patients were classified into two groups based on the time of CALGB 9343 publication: (i) pre-CALGB (up to 2004), and (ii) post-CALGB (2005-2012). Clinicopathological and sociodemographic variables were compared between pre- and post-CALGB groups. Chi-square and multivariable logistic regression were employed, with the omission of adjuvant RT as the primary outcome in the regression analysis. RESULTS: Radiation therapy usage decreased by 4.1% after CALGB publication (on average 71.6% pre-CALGB vs. 67.5% post-CALGB; p<0.0001). Almost one-third of women aged ≥85 years received RT in the post-CALGB group. In a multivariable model, the variables significantly associated with increased odds for omission of RT in the post-CALGB group were: advanced age, African-American, increased great circle distance, therapy under academic research program, residents of East South-Central region, living in a rural population <2,500 not adjacent to a metropolitan area, low income level, Medicaid recipients, high comorbidity index, small tumor, well-differentiated histology, residual tumor, and lack of receipt of chemotherapy and anti-hormonal therapy. CONCLUSION: During the study period, the CALGB trial publication had a minimal impact on the rate of adjuvant RT use among elderly women with small, ER-positive breast cancers. Significant variation in RT usage existed across sociodemographic strata.

Cost analysis of establishing a relationship between a surgical program in the US and Vietnam.

"Twinning" refers to a constructive partnership between hospitals in developed and developing nations. Such an effort may contribute immensely to capacity building for the developing nation, but one of the reasons given for the lack of sustainability is cost. We share a detailed operating cost analysis of our recent experience with an institution in Vietnam. We were awarded a 1-year $54,000 grant from the Vietnam Education Foundation (VEF) to conduct a live tele-video conferencing course on the "Fundamentals of Clinical Surgery" with Thai Binh Medical University (TBMU). In-country lectures as well as an assessment of the needs at TBMU were performed. Total financial assistance and expenditures were tabulated to assess up-front infrastructure investment and annual cost required to sustain the program. The total amount of direct money ($66,686) and in-kind services ($70,276) was $136,962. The initial infrastructure cost was $41,085, which represented 62% of the direct money received. The annual cost to sustain the program was approximately $11,948. We concluded that the annual cost to maintain a "twinning" program was relatively low, and the efforts to sustain a "twinning" program were financially feasible and worthwhile endeavors. "Twinning" should be a critical part of the surgical humanitarian volunteerism effort.