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      Association Between Medicaid Expansion Under the Affordable Care Act and Survival Among Newly Diagnosed Cancer Patients

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          Abstract

          Background

          Medicaid expansion under the Affordable Care Act (ACA) is associated with increased insurance coverage among patients with cancer. Whether these gains translate to improved survival is largely unknown. This study examines changes in 2-year survival among patients newly diagnosed with cancer following the ACA Medicaid expansion.

          Methods

          Patients aged 18-62 years from 42 states’ population-based cancer registries diagnosed pre (2010-2012) and post (2014-2016) ACA Medicaid expansion were followed through September 30, 2013, and December 31, 2017, respectively. Difference-in-differences (DD) analysis of 2-year overall survival was stratified by sex, race and ethnicity, census tract–level poverty, and rurality.

          Results

          A total of 2 555 302 patients diagnosed with cancer were included from Medicaid expansion (n = 1 523 585) and nonexpansion (n = 1 031 717) states. The 2-year overall survival increased from 80.58% pre-ACA to 82.23% post-ACA in expansion states and from 78.71% to 80.04% in nonexpansion states, resulting in a net increase of 0.44 percentage points (ppt) (95% confidence interval [CI] = 0.24ppt to 0.64ppt) in expansion states after adjusting for sociodemographic factors. By cancer site, the net increase was greater for colorectal cancer (DD = 0.90ppt, 95% CI = 0.19ppt to 1.60ppt), lung cancer (DD = 1.29ppt, 95% CI = 0.50ppt to 2.08ppt), non-Hodgkin lymphoma (DD = 1.07ppt, 95% CI = 0.14ppt to 1.99ppt), pancreatic cancer (DD = 1.80ppt, 95% CI = 0.40ppt to 3.21ppt), and liver cancer (DD = 2.57ppt, 95% CI = 1.00ppt to 4.15ppt). The improvement in 2-year overall survival was larger among non-Hispanic Black patients (DD = 0.72ppt, 95% CI = 0.12ppt to 1.31ppt) and patients residing in rural areas (DD = 1.48ppt, 95% CI= -0.26ppt to 3.23ppt), leading to narrowing survival disparities by race and rurality.

          Conclusions

          Medicaid expansion was associated with greater increase in 2-year overall survival, and the increase was prominent among non-Hispanic Blacks and in rural areas, highlighting the role of Medicaid expansion in reducing health disparities. Future studies should monitor changes in longer-term health outcomes following the ACA.

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          Cancer Statistics, 2021

          Rebecca Siegel, Kimberly D Miller, Hannah Fuchs … (2021)
          Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths in the United States and compiles the most recent data on population-based cancer occurrence. Incidence data (through 2017) were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data (through 2018) were collected by the National Center for Health Statistics. In 2021, 1,898,160 new cancer cases and 608,570 cancer deaths are projected to occur in the United States. After increasing for most of the 20th century, the cancer death rate has fallen continuously from its peak in 1991 through 2018, for a total decline of 31%, because of reductions in smoking and improvements in early detection and treatment. This translates to 3.2 million fewer cancer deaths than would have occurred if peak rates had persisted. Long-term declines in mortality for the 4 leading cancers have halted for prostate cancer and slowed for breast and colorectal cancers, but accelerated for lung cancer, which accounted for almost one-half of the total mortality decline from 2014 to 2018. The pace of the annual decline in lung cancer mortality doubled from 3.1% during 2009 through 2013 to 5.5% during 2014 through 2018 in men, from 1.8% to 4.4% in women, and from 2.4% to 5% overall. This trend coincides with steady declines in incidence (2.2%-2.3%) but rapid gains in survival specifically for nonsmall cell lung cancer (NSCLC). For example, NSCLC 2-year relative survival increased from 34% for persons diagnosed during 2009 through 2010 to 42% during 2015 through 2016, including absolute increases of 5% to 6% for every stage of diagnosis; survival for small cell lung cancer remained at 14% to 15%. Improved treatment accelerated progress against lung cancer and drove a record drop in overall cancer mortality, despite slowing momentum for other common cancers.
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            Early palliative care for patients with metastatic non-small-cell lung cancer.

            Jennifer Temel, Joseph A. Greer, Alona Muzikansky … (2010)
            Patients with metastatic non-small-cell lung cancer have a substantial symptom burden and may receive aggressive care at the end of life. We examined the effect of introducing palliative care early after diagnosis on patient-reported outcomes and end-of-life care among ambulatory patients with newly diagnosed disease. We randomly assigned patients with newly diagnosed metastatic non-small-cell lung cancer to receive either early palliative care integrated with standard oncologic care or standard oncologic care alone. Quality of life and mood were assessed at baseline and at 12 weeks with the use of the Functional Assessment of Cancer Therapy-Lung (FACT-L) scale and the Hospital Anxiety and Depression Scale, respectively. The primary outcome was the change in the quality of life at 12 weeks. Data on end-of-life care were collected from electronic medical records. Of the 151 patients who underwent randomization, 27 died by 12 weeks and 107 (86% of the remaining patients) completed assessments. Patients assigned to early palliative care had a better quality of life than did patients assigned to standard care (mean score on the FACT-L scale [in which scores range from 0 to 136, with higher scores indicating better quality of life], 98.0 vs. 91.5; P=0.03). In addition, fewer patients in the palliative care group than in the standard care group had depressive symptoms (16% vs. 38%, P=0.01). Despite the fact that fewer patients in the early palliative care group than in the standard care group received aggressive end-of-life care (33% vs. 54%, P=0.05), median survival was longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P=0.02). Among patients with metastatic non-small-cell lung cancer, early palliative care led to significant improvements in both quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival. (Funded by an American Society of Clinical Oncology Career Development Award and philanthropic gifts; ClinicalTrials.gov number, NCT01038271.)
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              CBTRUS Statistical Report: Primary Brain and Other Central Nervous System Tumors Diagnosed in the United States in 2014–2018

              Quinn Ostrom, Gino Cioffi, Kristin Waite … (2021)
              The Central Brain Tumor Registry of the United States (CBTRUS), in collaboration with the Centers for Disease Control and Prevention (CDC) and National Cancer Institute (NCI), is the largest population-based cancer registry focused exclusively on primary brain and other central nervous system (CNS) tumors in the United States (US) and represents the entire US population. This report contains the most up-to-date population-based data on primary brain tumors available and supersedes all previous reports in terms of completeness and accuracy and is the first CBTRUS Report to provide the distribution of molecular markers for selected brain and CNS tumor histologies. All rates are age-adjusted using the 2000 US standard population and presented per 100,000 population. The average annual age-adjusted incidence rate (AAAIR) of all malignant and non-malignant brain and other CNS tumors was 24.25 (Malignant AAAIR=7.06, Non-malignant AAAIR=17.18). This overall rate was higher in females compared to males (26.95 versus 21.35) and non-Hispanics compared to Hispanics (24.68 versus 22.12). The most commonly occurring malignant brain and other CNS tumor was glioblastoma (14.3% of all tumors and 49.1% of malignant tumors), and the most common non-malignant tumor was meningioma (39.0% of all tumors and 54.5% of non-malignant tumors). Glioblastoma was more common in males, and meningioma was more common in females. In children and adolescents (age 0–19 years), the incidence rate of all primary brain and other CNS tumors was 6.21. An estimated 88,190 new cases of malignant and non-malignant brain and other CNS tumors are expected to be diagnosed in the US population in 2021 (25,690 malignant and 62,500 non-malignant). There were 83,029 deaths attributed to malignant brain and other CNS tumors between 2014 and 2018. This represents an average annual mortality rate of 4.43 per 100,000 and an average of 16,606 deaths per year. The five-year relative survival rate following diagnosis of a malignant brain and other CNS tumor was 35.6%, for a non-malignant brain and other CNS tumors the five-year relative survival rate was 91.8%.
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                Author and article information

                Contributors
                Journal
                Title: JNCI: Journal of the National Cancer Institute
                Publisher: Oxford University Press (OUP)
                ISSN (Print): 0027-8874
                ISSN (Electronic): 1460-2105
                Publication date Created: May 18 2022
                Publication date (Electronic): May 18 2022
                Affiliations
                [1 ]Surveillance & Health Equity Science, American Cancer Society, Atlanta, GA, USA
                [2 ]Cancer Data Registry of Idaho, Boise, ID, USA
                Article
                DOI: 10.1093/jnci/djac077
                PubMed ID: 35583373
                SO-VID: 5902ce02-4805-4c0a-a1a2-098f6bc79395
                Copyright © © 2022
                License:

                https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model

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