Association of Medicaid expansion with 2-year survival and time to treatment initiation in gastrointestinal cancer patients: A National Cancer Database study.

INTRODUCTION: We evaluated whether Medicaid expansion (ME) was associated with improved 2-year survival and time to treatment initiation (TTI) among patients with gastrointestinal (GI) cancer. METHODS: GI cancer patients diagnosed 40-64 years were queried from the National Cancer Database. Those diagnosed from 2010 to 2012 were considered pre-expansion; those diagnosed from 2014 to 2016 were considered post-expansion. Cox models estimated hazard ratios and 95% confidence intervals (CIs) for 2-year overall survival. Generalized estimating equations (GEE) estimated odds ratios (OR) and 95% CI of TTI within 30- and 90 days. Multivariable Difference-in-Difference models were used to compare expansion/nonexpansion cohorts pre-/post-expansion, adjusting for patient, clinical, and hospital factors. RESULTS: 377,063 patients were included. No significant difference in 2-year survival was demonstrated across ME and non-ME states overall or in site-based subgroup analysis. In stage-based subgroup analysis, 2-year survival significantly improved among stage II cancer, with an 8% decreased hazard of death at 2 years (0.92; 0.87-0.97). Those with stage IV had a 4% increased hazard of death at 2 years (1.04; 1.01-1.07). Multivariable GEE models showed increased TTI within 30 days (1.12; 1.09-1.16) and 90 days (1.22; 1.17-1.27). Site-based subgroup analyses indicated increased likelihood of TTI within 30 and 90 days among colon, liver, pancreas, rectum, and stomach cancers, by 30 days for small intestinal cancer, and by 90 days for esophageal cancer. In subgroup analyses, all stages experienced improved odds of TTI within 30 and 90 days. CONCLUSION: ME was not associated with significant improvement in 2-year survival for those with GI cancer. Although TTI increased after ME for both cohorts, the 30- and 90-day odds of TTI was higher for those from ME compared with non-ME states. Our findings add to growing evidence of associations with ME for those diagnosed with GI cancer.

Assessment of Physical Activity and Healthy Eating Behaviors Among US Adults Receiving Bariatric Surgery.

Importance: Bariatric surgery effectively treats severe obesity and metabolic diseases. However, individual outcomes vary depending on sustainable lifestyle change. Little is known about lifestyle patterns after bariatric surgery among the US population. Objective: To compare the level of physical activity and eating behavior among postbariatric surgery patients, individuals eligible for surgery, and those with normal weight. Design, Setting, and Participants: A cross-sectional study using nationally representative survey data from National Health and Nutrition Examination Survey 2015-2018. Respondents included for analysis were age 18 years or older, and categorized by individuals with normal weight, individuals who received bariatric surgery, and individuals clinically eligible for bariatric surgery. Analyses were performed from February to October 2021. Main Outcomes and Measures: Self-reported measures were used to assess physical activity (moderate-to-vigorous physical activity [MVPA], sedentary activity, and whether PA guidelines were met) and eating behaviors (total energy intake and Healthy Eating Index [HEI]-2015 diet quality scores). Results: Of 4659 study participants (mean [SD] age, 46.1 [18.6] years; 2638 [weighted percentage, 58.8%] women; 1114 [weighted percentage, 12.7%] Black, 1570 [weighted percentage, 68.6%] White), 132 (3.7%) reported that they had undergone any bariatric surgery. Median (IQR) time since surgery was 7 (3-10) years. After propensity-score weighting, individuals who underwent bariatric surgery reported more time spent in MVPA than those eligible for surgery (147.9 min/wk vs 97.4 min/wk). Among respondents with normal weight, 45.6% (95% CI, 40.8% to 52.4%) reported meeting PA guidelines, almost 2 times higher than those in the bariatric surgery (23.1%; 95% CI, 13.8% to 32.4%) or in the surgery-eligible group (20.3%; 95% CI, 15.6% to 25.1%). Propensity-score weighted overall HEI was higher for individuals with normal weight (54.4; 95% CI, 53.0 to 55.9) than those who underwent bariatric surgery (50.0; 95% CI, 47.2 to 52.9) or were eligible for the surgery (48.0; 95% CI, 46.0 to 50.0). Across all HEI components, mean scores were similar between the bariatric surgery and surgery-eligible groups. Total energy intake was the lowest among those who underwent bariatric surgery (1746 kcal/d; 95% CI, 1554 to 1937 kcal/d), followed by those with normal weight (1943 kcal/d; 95% CI, 1873 to 2013 kcal/d) and those eligible for bariatric surgery (2040 kcal/d; 1953 to 2128 kcal/d). Conclusions and Relevance: In this cross-sectional study, individuals who underwent bariatric surgery had beneficial lifestyle patterns compared with those eligible for surgery; however, these improvements seemed suboptimal based on the current guidelines. Efforts are needed to incorporate benefits of physical activity and a healthy, balanced diet in postbariatric care.

Assessment of US Preventive Services Task Force Guideline-Concordant Cervical Cancer Screening Rates and Reasons for Underscreening by Age, Race and Ethnicity, Sexual Orientation, Rurality, and Insurance, 2005 to 2019.

Importance: Cervical cancer screening rates are suboptimal in the US. Population-based assessment of reasons for not receiving screening is needed, particularly among women from historically underserved demographic groups. Objective: To estimate changes in US Preventive Service Task Force guideline-concordant cervical cancer screening over time and assess the reasons women do not receive up-to-date screening by sociodemographic factors. Design, Setting, and Participants: This pooled population-based cross-sectional study used data from the US National Health Interview Survey from 2005 and 2019. A total of 20 557 women (weighted, 113.1 million women) aged 21 to 65 years without previous hysterectomy were included. Analyses were conducted from March 30 to August 19, 2021. Exposures: Sociodemographic factors, including age, race and ethnicity, sexual orientation, rurality of residence, and health insurance type. Main Outcomes and Measures: Primary outcomes were US Preventive Services Task Force guideline-concordant cervical cancer screening rates and self-reported primary reasons for not receiving up-to-date screening. For 2005, up-to-date screening was defined as screening every 3 years for women aged 21 to 65 years. For 2019, up-to-date screening was defined as screening every 3 years with a Papanicolaou test alone for women aged 21 to 29 years and screening every 3 years with a Papanicolaou test alone or every 5 years with high-risk human papillomavirus testing or cotesting for women aged 30 to 65 years. Population estimation included sampling weights. Results: Among 20 557 women (weighted, 113.1 million women) included in the study, most were aged 30 to 65 years (16 219 women; weighted, 86.3 million women [76.3%]) and had private insurance (13 571 women; weighted, 75.8 million women [67.0%]). With regard to race and ethnicity, 997 women (weighted, 6.9 million women [6.1%]) were Asian, 3821 women (weighted, 19.5 million women [17.2%]) were Hispanic, 2862 women (weighted, 14.8 million women [13.1%]) were non-Hispanic Black, 12 423 women (weighted, 69.0 million women [61.0%]) were non-Hispanic White, and 453 women (weighted, 3.0 million women [2.7%]) were of other races and/or ethnicities (including Alaska Native and American Indian [weighted, 955 000 women (0.8%)] and other single and multiple races or ethnicities [weighted, 2.0 million women (1.8%)]). In 2019, women aged 21 to 29 years had a significantly higher rate of overdue screening (29.1%) vs women aged 30 to 65 years (21.1%; P < .001). In both age groups, the proportion of women without up-to-date screening increased significantly from 2005 to 2019 (from 14.4% to 23.0%; P < .001). Significantly higher rates of overdue screening were found among those of Asian vs non-Hispanic White race and ethnicity (31.4% vs 20.1%; P = .01), those identifying as LGBQ+ (gender identity was not assessed because of a small sample) vs heterosexual (32.0% vs 22.2%; P < .001), those living in rural vs urban areas (26.2% vs 22.6%; P = .04), and those without insurance vs those with private insurance (41.7% vs 18.1%; P < .001). The most common reason for not receiving timely screening across all groups was lack of knowledge, ranging from 47.2% of women identifying as LGBQ+ to 64.4% of women with Hispanic ethnicity. Previous receipt of a human papillomavirus vaccine was not a primary reason for not having up-to-date screening (<1% of responses). From 2005 to 2019, among women aged 30 to 65 years, lack of access decreased significantly as a primary reason for not receiving screening (from 21.8% to 9.7%), whereas lack of knowledge (from 45.2% to 54.8%) and not receiving recommendations from health care professionals (from 5.9% to 12.0%) increased significantly. Conclusions and Relevance: This cross-sectional study found that cervical cancer screening that was concordant with US Preventive Services Task Force guidelines decreased in the US between 2005 and 2019, with lack of knowledge reported as the biggest barrier to receiving timely screening. Campaigns addressing patient knowledge and provider communication may help to improve screening rates, and cultural adaptation of interventions is needed to reduce existing disparities.

Patient-provider discussion about emotional and social needs, mental health outcomes, and benefit finding among U.S. Adults living with cancer.

BACKGROUND: A discussion about patient's nonmedical needs during treatment is considered a crucial component of high-quality patient-provider communication. We examined whether having a patient-provider discussion about cancer patients' emotional and social needs is associated with their psychological well-being. METHODS: Using the 2016-2017 Medical Expenditure Panel Survey-Experiences with Cancer Survivorship Supplement (MEPS-ECSS) data, we identified the cancer survivors in the United States (US) who reported having a detailed discussion about emotional and social needs during cancer care. We used multivariable logistic regression to assess the association between having a patient-provider discussion and the patients' psychological well-being outcomes (depressive symptoms, severe psychological distress, and worrying about cancer recurrence/worsening condition) and benefit finding experience after a cancer diagnosis. RESULTS: Among 1433 respondents (equivalent to 13.8 million cancer survivors in the US), only 33.6% reported having a detailed patient-provider discussion about their emotional and social needs. Having a discussion was associated with 55% lower odds (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.26-0.77) of having depressive symptoms and 97% higher odds (OR, 1.97; 95% CI, 1.46-2.66) of having benefit finding experience. There was no statistically significant association between patient-provider discussion and psychological distress or worrying about cancer recurrence/worsening. CONCLUSION: Detailed patient-provider discussion about the cancer patients' emotional and social needs was associated with a lower likelihood of depressive symptoms and a higher likelihood of experiencing benefit finding. These findings stress the importance of improving the patient-provider discussion about psychosocial needs in cancer survivorship.