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Impact of the Affordable Care Act on Presentation, Treatment, and Outcomes of Intrahepatic Cholangiocarcinoma. J Gastrointest Surg 2023; 27:262-272. [PMID: 36400904 DOI: 10.1007/s11605-022-05496-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 10/20/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Affordable Care Act (ACA) transformed the US healthcare system, expanding healthcare insurance coverage. However, its impact on rare malignancies that lack an established screening strategy such as intrahepatic cholangiocarcinoma (ICC) remains ill-defined. METHODS Patients diagnosed with ICC were identified from the National Cancer Database and divided relative to ACA implementation. Multivariate logistic regression analyses were performed to evaluate association with stage at diagnosis, receipt of surgical and multimodal treatments, and survival. RESULTS Among the 9095 patients, 5636 (62.0%) were diagnosed before and 3459 (38.0%) after the implementation of the ACA. Across US regions, rates of early-stage diagnosis increased in the post-ACA era (Northeast, 62.9% vs. 85.2%; South, 63.7% vs. 78.5%; Midwest, 62.1% vs. 83.4%; West, 55.5% vs. 75.4%; p < 0.001). On multivariate analyses, the post-ACA era was associated with increased early-stage diagnosis (OR = 2.19; 95% CI 1.79-2.69), and receipt of surgical treatment (OR = 1.19, 95% CI 1.03-1.38) (both p < 0.01). Furthermore, the ACA's Medicaid expansion (ME) was also associated with improved overall survival (HR = 0.89, 95% CI 0.80-0.99, p = 0.038). Of note, although the odds of receiving surgical treatment increased after ACA for non-Hispanic White patients (OR = 1.34; 95% CI 1.20-1.49; p < 0.001), no such effect was observed in non-Hispanic Black (OR = 1.01, 95% CI 0.71-1.45), Hispanic (OR = 1.44, 95% CI 0.99-2.09), or others (OR = 1.43, 95% CI 0.98-2.10) (all p > 0.05). CONCLUSIONS The implementation of the ACA increased rates of early diagnosis and receipt of surgical treatment. Additionally, ME improved short- and long-term outcomes. However, racial and socioeconomic disparities persist, resulting in inequitable access to care and outcomes for patients with ICC.
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Bhatia S, Landier W, Paskett ED, Peters KB, Merrill JK, Phillips J, Osarogiagbon RU. Rural-Urban Disparities in Cancer Outcomes: Opportunities for Future Research. J Natl Cancer Inst 2022; 114:940-952. [PMID: 35148389 PMCID: PMC9275775 DOI: 10.1093/jnci/djac030] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/27/2021] [Accepted: 02/01/2022] [Indexed: 01/12/2023] Open
Abstract
Cancer care disparities among rural populations are increasingly documented and may be worsening, likely because of the impact of rurality on access to state-of-the-art cancer prevention, diagnosis, and treatment services, as well as higher rates of risk factors such as smoking and obesity. In 2018, the American Society of Clinical Oncology undertook an initiative to understand and address factors contributing to rural cancer care disparities. A key pillar of this initiative was to identify knowledge gaps and promote the research needed to understand the magnitude of difference in outcomes in rural vs nonrural settings, the drivers of those differences, and interventions to address them. The purpose of this review is to describe continued knowledge gaps and areas of priority research to address them. We conducted a comprehensive literature review by searching the PubMed (Medline), Embase, Web of Science, and Cochrane Library databases for studies published in English between 1971 and 2021 and restricted to primary reports from populations in the United States and abstracted data to synthesize current evidence and identify continued gaps in knowledge. Our review identified continuing gaps in the literature regarding the underlying causes of rural-urban disparities in cancer outcomes. Rapid advances in cancer care will worsen existing disparities in outcomes for rural patients without directed effort to understand and address barriers to high-quality care in these areas. Research should be prioritized to address ongoing knowledge gaps about the drivers of rurality-based disparities and preventative and corrective interventions.
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Affiliation(s)
- Smita Bhatia
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Wendy Landier
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
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Lee RM, Liu Y, Gamboa AC, Zaidi MY, Kooby DA, Shah MM, Cardona K, Russell MC, Maithel SK. Race, ethnicity, and socioeconomic factors in cholangiocarcinoma: What is driving disparities in receipt of treatment? J Surg Oncol 2019; 120:611-623. [PMID: 31301148 PMCID: PMC6752195 DOI: 10.1002/jso.25632] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 06/28/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Race/ethnicity and socioeconomic factors are associated with worse cancer outcomes. Our aim was to determine the association of these factors with receipt of surgery and multimodality therapy for cholangiocarcinoma. METHODS Patients with cholangiocarcincoma in the National Cancer Database were identified. Racial/ethnic groups were defined as non-Hispanic White, non-Hispanic Black, Asian, and Hispanic. Socioeconomic factors were insurance status, income, and education. RESULTS Of 12 095 patients with non-metastatic cholangiocarcinoma, 42% received surgery. Black race was associated with decreased odds of receiving surgery (odds ratio [OR]: 0.66l; P < .001) compared to White patients. Socioeconomic factors accounted for 21% of this disparity. Accounting for socioeconomic and clinicopathologic variables, Black race (OR: 0.73; P < .001), uninsured status (OR: 0.43; P < .001), and Medicaid insurance (OR: 0.63; P < .001) were all associated with decreased receipt of surgery. Of 4808 patients who received surgery, 47% received multimodality therapy. There were no racial/ethnic or socioeconomic differences in receipt of multimodality therapy once patients accessed surgical care. Similar results were seen in patients with advanced disease who received chemotherapy as primary treatment. CONCLUSION Racial/ethnic and socioeconomic disparities exist in treatment for cholangiocarcinoma, however only for primary treatment. In patients who received surgery or chemotherapy, there were no disparities in receipt of multimodality therapy. This emphasizes the need to improve initial access to health care for minority and socioeconomical disadvantaged patients.
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Affiliation(s)
- Rachel M. Lee
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Yuan Liu
- Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, Georgia
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Adriana C. Gamboa
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mohammad Y. Zaidi
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - David A. Kooby
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mihir M. Shah
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Maria C. Russell
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K. Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Rural patients are at risk for increased stage at presentation and diminished overall survival in osteosarcoma. Cancer Epidemiol 2019; 61:119-123. [DOI: 10.1016/j.canep.2019.05.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 04/25/2019] [Accepted: 05/29/2019] [Indexed: 11/20/2022]
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Afshar N, English DR, Milne RL. Rural-urban residence and cancer survival in high-income countries: A systematic review. Cancer 2019; 125:2172-2184. [PMID: 30933318 DOI: 10.1002/cncr.32073] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 02/06/2019] [Accepted: 02/24/2019] [Indexed: 12/21/2022]
Abstract
There is some evidence that place of residence is associated with cancer survival, but the findings are inconsistent, and the underlying mechanisms by which residential location might affect survival are not well understood. We conducted a systematic review of observational studies investigating the association of rural versus urban residence with cancer survival in high-income countries. We searched the Ovid Medline, EMBASE, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases up to May 31, 2016. Forty-five studies published between 1984 and 2016 were included. We extracted unadjusted and adjusted relative risk estimates with the corresponding 95% confidence intervals. Most studies reported worse survival for cancer patients living in rural areas than those in urban regions. The most consistent evidence, observed across several studies, was for colorectal, lung, and prostate cancer. Of the included studies, 18 did not account for socio-economic position. Lower survival for more disadvantaged patients is well documented; therefore, it could be beneficial for future research to take socio-economic factors into consideration when assessing rural/urban differences in cancer survival. Some studies cited differential stage at diagnosis and treatment modalities as major contributing factors to regional inequalities in cancer survival. Further research is needed to disentangle the mediating effects of these factors, which may help to establish effective interventions to improve survival for patients living outside major cities.
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Affiliation(s)
- Nina Afshar
- Cancer Epidemiology and Intelligence Division, Cancer Council Victoria, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Dallas R English
- Cancer Epidemiology and Intelligence Division, Cancer Council Victoria, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Roger L Milne
- Cancer Epidemiology and Intelligence Division, Cancer Council Victoria, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
- Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
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Lee GC, Ferrone CR, Tanabe KK, Lillemoe KD, Blaszkowsky LS, Zhu AX, Hong TS, Qadan M. Predictors of adjuvant treatment and survival in patients with intrahepatic cholangiocarcinoma who undergo resection. Am J Surg 2019; 218:959-966. [PMID: 30871788 DOI: 10.1016/j.amjsurg.2019.02.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 02/21/2019] [Accepted: 02/27/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Administration of adjuvant therapy (AT) in patients with intrahepatic cholangiocarcinoma (ICC) remains inconsistent despite recent trial data. This study investigates predictors of receipt of AT and survival. METHODS Patients with ICC who underwent resection were identified using the NCDB (2004-2014). Logistic regression and Cox analysis were used to determine predictors of AT and survival, respectively. "High-risk" was defined as positive margins/nodes or stage III/IVa disease. RESULTS 2813 patients were identified, of whom 42.3% received AT. Patients with positive margins, positive nodes, and higher stage tended to receive AT (p < 0.001). Black patients and patients with Medicare/Medicaid were less likely to receive AT. In "high-risk" patients, AT was associated with lower mortality (HR 0.66, 95% CI 0.56-0.78, p < 0.001). CONCLUSIONS AT after ICC resection is associated with improved survival in patients with positive margins, positive nodes, and stage III/IVa disease. There are disparities and regional variations in the receipt of AT.
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Affiliation(s)
- Grace C Lee
- Department of Surgery, Massachusetts General Hospital, Boston, MA, 02114, USA; Newton Wellesley Hospital, Newton, MA 02462, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Kenneth K Tanabe
- Department of Surgery, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA, 02114, USA; Newton Wellesley Hospital, Newton, MA 02462, USA
| | - Lawrence S Blaszkowsky
- Newton Wellesley Hospital, Newton, MA 02462, USA; Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Andrew X Zhu
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Theodore S Hong
- Newton Wellesley Hospital, Newton, MA 02462, USA; Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA, 02114, USA; Newton Wellesley Hospital, Newton, MA 02462, USA.
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The Effects of Travel Burden on Outcomes After Resection of Extrahepatic Biliary Malignancies: Results from the US Extrahepatic Biliary Consortium. J Gastrointest Surg 2017; 21:2016-2024. [PMID: 28986752 PMCID: PMC5909109 DOI: 10.1007/s11605-017-3537-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 08/07/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical resection of extrahepatic biliary malignancies has been increasingly centralized at high-volume tertiary care centers. While this has improved outcomes overall, increased travel burden has been associated with worse survival for many other malignancies. We hypothesized that longer travel distances are associated with worse outcomes for these patients as well. STUDY DESIGN Data was analyzed from the US Extrahepatic Biliary Consortium database, which retrospectively reviewed patients who received resection of extrahepatic biliary malignancies at 10 high-volume centers. Driving distance to the patient's treatment center was measured for 1025 patients. These were divided into four quartiles for analysis: < 24.5, 24.5-57.2, 57.2-117, and < 117 mi. Cox proportional hazard models were then used to measure differences in overall survival. RESULTS No difference was found between the groups in severity of disease or post-operative complications. The median overall survival in each quartile was as follows: 1st = 1.91, 2nd = 1.60, 3rd = 1.30, and 4th = 1.39 years. Patients in the 3rd and 4th quartile had a significantly lower median household income (p = 0.0001) and a greater proportion Caucasian race (p = 0.0001). However, neither of these was independently associated with overall survival. The two furthest quartiles were found to have decreased overall survival (HR = 1.39, CI = 1.12-1.73 and HR = 1.3, CI = 1.04-1.62), with quartile 3 remaining significant after multivariate analysis (HR = 1.45, CI = 1.04-2.0, p = 0.028). CONCLUSIONS Longer travel distances were associated with decreased overall survival, especially in the 3rd quartile of our study. Patients traveling longer distances also had a lower household income, suggesting that these patients have significant barriers to care.
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Mosadeghi S, Liu B, Bhuket T, Wong RJ. Sex-specific and race/ethnicity-specific disparities in cholangiocarcinoma incidence and prevalence in the USA: An updated analysis of the 2000-2011 Surveillance, Epidemiology and End Results registry. Hepatol Res 2016; 46:669-77. [PMID: 26508039 DOI: 10.1111/hepr.12605] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 10/10/2015] [Accepted: 10/13/2015] [Indexed: 12/18/2022]
Abstract
AIM Cholangiocarcinoma (CCA) is an uncommon but lethal malignancy with an increasing worldwide incidence of intrahepatic cholangiocarcinoma (ICC), but decreasing incidence of extrahepatic cholangiocarcinoma (ECC). To evaluate age-specific, sex-specific, race/ethnicity-specific variations in CCA incidence in the USA. METHODS Using population-based cancer registry data from the 2000-2011 Surveillance, Epidemiology and End Results registry, we retrospectively evaluated age-specific, sex-specific, race/ethnicity-specific variations in incidence and prevalence of CCA stratified by ICC and ECC subtypes among adults in the USA. RESULTS A total of 11 296 patients with ICC and 8672 patients with ECC were identified. ICC incidence was significantly higher than ECC incidence (1.6 vs 1.3 per 100 000/year, P < 0.01). Among all race/ethnic groups and among both ICC and ECC, Asians had the highest cancer incidence. When stratified by age, CCA incidence increased with age among all groups; however, the rising incidence was most rapid among Asians. For example, among patients aged 80 years and over, the incidence of ICC among Asians was nearly twice the incidence among non-Hispanic whites (13.8 vs 7.2 per 100 000/year). Overall, CCA incidence was higher among men compared with women, and with increasing age, this sex-specific disparity was more pronounced. For example, among patients aged 80 years and over, the incidence of ICC was 9.8 per 100 000/year among men and 6.9 per 100 000/year among women. CONCLUSION Among adults with CCA in the USA, increasing age was associated with increasing incidence of CCA. In addition, sex-specific and race/ethnicity-specific disparities were seen with the highest incidence of CCA among men and among Asians.
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Affiliation(s)
- Sasan Mosadeghi
- Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, California, USA
| | - Benny Liu
- Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, California, USA
| | - Taft Bhuket
- Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, California, USA
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, California, USA
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