A novel opportunity in minimally invasive colorectal cancer therapy: defining a role for endoscopic submucosal dissection in the United States

Impact of the affordable care act's medicaid expansion on presentation stage and perioperative outcomes of colorectal cancer

BACKGROUND AND OBJECTIVES

Medicaid expansion has improved healthcare coverage and preventive health service use. To what extent this has resulted in earlier stage colorectal cancer diagnoses and impacted perioperative outcomes is unclear.

METHODS

This was a retrospective difference-in-difference study using the National Cancer Database on adults (40-64) with Medicaid or no insurance, diagnosed with colorectal adenocarcinomas before (2010-2013) and after (2015-2018) expansion. The primary outcome was early-stage (American Joint Committee on Cancer Stage 0-1) diagnosis. The secondary outcomes were rate of local excision, emergency surgery, postoperative length of stay, rates of minimally invasive surgery, postoperative mortality, and overall survival (OS).

RESULTS

Medicaid expansion was associated with an increase in early-stage diagnoses for patients with colorectal cancers (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 1.15-1.43), an increase in local excision (OR: 1.39, 95% CI: 1.13-1.69), and a decreased rate of emergent surgery (OR: 0.85, 95% CI: 0.75-0.97) and 90-day mortality (OR: 0.75, 95% CI: 0.59-0.97). Additionally, patients in expansion states postexpansion had an improved 5-year OS (hazard ratio: 0.88, 95% CI: 0.83-0.94).

CONCLUSIONS

Insurance coverage expansion may be particularly important for optimizing stage of diagnosis, subsequent survival, and perioperative outcomes for socioeconomically vulnerable patients.

Colorectal Endoscopic Submucosal Dissection: Past, Present, and Factors Impacting Future Dissemination

First performed in the stomach for removal of localized gastric tumors, endoscopic submucosal dissection (ESD) has evolved into a technique that is increasingly being employed to resect colorectal lesions. As opposed to endoscopic mucosal resection (EMR), ESD allows the endoscopist to remove large specimens en bloc to provide accurate pathologic evaluation and lower local recurrence rates. ESD is an ideal technique for resection of lesions without lymph node metastases and is becoming the standard of care in Japan as outcomes data has proven it to be equally efficacious, less invasive, and inexpensive as compared with surgery; however, potential risk for complications is high and the procedure is currently not widely available in the Western world. As more interest, endoscopist training, and data supporting the technique's use mount, ESD will also likely become the standard of care in the Western world for resection of localized colorectal lesions.