Receipt of chemotherapy among medicare patients with cancer by type of supplemental insurance

Accuracy of Cancer Registry Primary Payer Information and Implications for Policy Research

BACKGROUND

Cancer registry-based "primary payer at diagnosis" (PPDx) data are commonly used to evaluate the effect of insurance on cancer care outcomes, yet little is known about how well they capture Medicaid or Medicare enrollment.

METHODS

We linked the National Cancer Institute's Surveillance, Epidemiology, and End Results registry data to monthly Centers for Medicare and Medicaid Services (CMS) Medicaid and Medicare enrollment records, state-year Medicaid policy, and managed care enrollment. We selected adults aged 19-64 years diagnosed between 2007 and 2011. We used bivariate analyses to compare PPDx to CMS enrollment at diagnosis month and assessed underreporting rates by patient characteristics and state-year policy.

RESULTS

PPDx reported 7.8% Medicare and 10.1% Medicaid, whereas CMS enrollment indicated 5.5% Medicare, 10.4% Medicaid, and 3.4% dual Medicare-Medicaid (N = 896,031). Positive predictive values for PPDx assignment to Medicaid and Medicare were 65.3% and 75.4%, with false negative rates of 52.0% and 33.8%, respectively. Medicaid underreporting was higher in low (56.5%) versus high (50.8%) poverty areas, for males (56.1%) versus females (48.9%), for Medicaid poverty expansion or waiver enrolled (63.8%) versus cash assistance-related eligibility (47.3%), and in states with large managed care enrollment (all P < 0.001). If Medicaid and Medicare enrollment data were used to edit PPDx, 12.0% of persons would switch primary payer assignment.

CONCLUSIONS

Registry-reported PPDx fails to fully capture Medicaid and Medicare enrollment, which may result in biased estimates of insurance-related policy impacts. Enhancement with objective enrollment data could reduce measurement error and bias in estimates necessary to support policy assessment.

Disparities of health expenditure associated with the experience of admission in long-term care hospital among patients with colorectal cancer in South Korea: A generalized estimating equation

With rising concerns about the functional role of long-term care hospitals in the Korean medical system, this study aimed to observe the experience of admission in the long-term care hospitals and their association with medical expenditures among patients with colorectal cancer, and to investigate disparities among vulnerable populations. Data were obtained from the National Health Insurance Senior Cohort Database in South Korea for the period 2008-2019. With 6,305 patients newly diagnosed with colorectal cancer between 2008 and 2015, we conducted a regression analysis using the Generalized Estimating Equation model with gamma distribution to investigate the association between health expenditure and the experience of long-term care hospitals. We also explored the interaction effect of disability or income, followed by subgroup analysis. Among patients who received care at long-term care hospitals, the health expenditure within one year and five years after the incidence of colorectal cancer was found to be higher than in those who did not receive such care. It was observed that the low-income and disabled groups experienced higher disparities in health expenditure. The rise in health expenditure highlights importance for functional improvement, aligning with these initial purpose of long-term care hospitals to address the growing healthcare needs of the elderly population and ensure efficient healthcare spending, of long-term care hospitals. To achieve this original intent, it is imperative for government initiatives to focus on reducing quality gaps in long-term care hospital services and addressing cost disparities among individuals with cancer, including those with disabilities or low-income.

Young Black Women May be More Likely to Have First Mammogram Cancers: A New Perspective in Breast Cancer Disparities

INTRODUCTION

Black women are diagnosed with breast cancer at earlier ages and are 42% more likely to die from the disease than White women. Recommendations for commencement of screening mammography remain discordant. This study sought to determine the frequency of first mammogram cancers among Black women versus other self-reported racial groups.

METHODS

In this retrospective cohort study, clinical and mammographic data were obtained from 738 women aged 40-45 years who underwent treatment for breast cancer between 2010 and 2019 within a single hospital system. First mammogram cancers were defined as those with tissue diagnoses within 3 months of baseline mammogram. Multivariate logistic regression was applied to assess variables associated with first mammogram cancer detection.

RESULTS

Black women were significantly more likely to have first mammogram cancer diagnoses (39/82, 47.6%) compared with White women (162/610, 26.6%) and other groups (16/46, 34.8%) [p < 0.001]. Black women were also more likely to have a body mass index > 30 (p < 0.001), higher clinical T categories (p = 0.02), and present with more advanced clinical stages (p = 0.03). Every month delay in mammographic screening beyond age 40 years (odds ratio [OR] 1.06, 95% confidence interval [CI] 1.05-1.07; p < 0.0001), Black race (OR 2.24, 95% CI 1.10-4.53; p = 0.03), and lack of private insurance (OR 2.41, 95% CI 1.22-4.73; p = 0.01) were associated with an increased likelihood of cancer detection on first mammogram.

CONCLUSION

Our findings suggests that Black women aged 40-45 years may be more likely to have cancer detected on their first mammogram and would benefit from starting screening mammography no later than age 40 years, and for those with elevated lifetime risk, even sooner.

Endocrine therapy initiation and overall survival outcomes with omission of radiation therapy in older Medicare patients with early‐stage hormone‐receptor‐positive breast cancer

BACKGROUND

Guidelines allow for the omission of radiotherapy in older women with early-stage, hormone-receptor-positive breast cancer, given that the patients receive adequate endocrine therapy (ET). However, the initiation of ET and survival outcomes after forgoing radiation therapy among these patients have not been well-studied.

METHODS

We identified patients aged 70 to 90 years old newly diagnosed in 2010-2015 with early-stage, hormone receptor positive, and human epidermal growth factor receptor 2 (HER2) negative (HR+/Her2-) breast cancer who received lumpectomy and omitted radiation therapy using the SEER-Medicare database. We examined the initiation of ET and the utilization patterns of ET using a multivariable logistic regression. We further examined the overall survival outcomes using Kaplan-Meier estimation and Cox proportional hazard model with inverse probability weighting.

RESULTS

Of the 2618 patients, 808 (30.9%) received no ET. The multivariable logistic regression showed that more recent years had better ET initiation (2013-2015 vs. 2010-2012: OR = 1.39, 95% CI:[1.16, 1.66]), while older patients (81-90 vs. 70-80: OR = 0.45, 95% CI:[0.38, 0.54]) were less likely to receive ET. Both the Kaplan-Meier estimation (log-rank p-value<0.0001) and the Cox proportional hazard model with inverse probability weighting (HR = 0.76, 95% CI:[0.58, 0.99]) showed that receiving ET was associated with better overall survival.

CONCLUSION

This population-based study suggests that a sizable proportion of patients who omitted radiation did not receive endocrine therapy and receiving endocrine therapy was beneficial among these patients. Although ET initiation has improved in more recent years, certain patient groups were still especially susceptible to no endocrine therapy.

Association between age and the presence and mortality of breast cancer synchronous brain metastases in the United States: A neglected SEER analysis

Background

The extent of the relationship between age and the presence of breast cancer synchronous brain metastases (BCSBMs) and mortality has not yet been well-identified or sufficiently quantified. We aimed to examine the association of age with the presence of BCSBMs and all-cause and cancer-specific mortality outcomes using the SEER database.

Methods

Age-associated risk of the presence and survival of BCSBMs were evaluated on a continuous scale (restricted cubic spline, RCS) with logistic or Cox regression models. The main endpoints were the presence of BCSBMs and all-cause mortality or cancer-specific mortality. Cox proportional hazards regression and competing risk models were used in survival analysis.

Results

Among 374,132 adult breast cancer patients, 1,441 (0.38%) had BMs. The presence of BCSBMs displayed a U-shaped relationship with age, with the highest point of the curve occurring at the age of 62. In both the younger (age ≤ 61) and older (age ≥ 62) groups, the observed curve showed a nearly linear relationship between age and the presence of BCSBMs. The relationship between age and all-cause mortality (ASM) and cancer-specific mortality (CSM) was linear. Older age at diagnosis was associated with a higher risk of ASM (HR 1.019, 95% CI: 1.013-1.024, p < 0.001) and CSM (HR 1.016, 95% CI: 1.010-1.023, p < 0.001) in multivariable Cox models. Age (sHR 1.007, 95% CI 1-1.013, p = 0.049) was substantially related to a significantly increased risk of CSM in competing risk models.

Conclusion

Age had a non-linear U-shaped relationship with the presence of BCSBMs and a linear relationship with BCSBMs mortality.

Linking Intermediate to Final “Real-World” Outcomes: Is Financial Toxicity a Reliable Predictor of Poorer Outcomes in Cancer?

Traditionally, economic evaluations are based on clinical trials with well-defined patient populations that exclude many patient types. By contrast, studies that incorporate general patient populations end up including those in lower income categories, some of whom have significant financial burdens (often described as financial toxicity) related to their care. Consideration of these patient burdens when examining the incremental cost-effectiveness of newer treatments from a clinical trial perspective can result in differing conclusions regarding cost-effectiveness. The challenge is to reliably assess the link between financial toxicity, quality of life and potential decisions to forego or delay care. It is also well-documented that these financial effects are not evenly distributed across populations, with those with low income and of black or Latino decent being most affected. There is a paucity of literature in this space, but some of the early work has suggested that for lung, breast, colorectal and ovarian cancers there are poorer quality-of-life scores and/or shorter overall survival for those experiencing financial toxicity. Hence, we may see both a lower quality of life and a shorter duration of life for these populations. If this is the case, additional considerations include: are the benefits of newer, more-expensive treatment strategies muted by the lack of adherence to these newer treatments due to financial concerns, and, if true, can these effects be effectively quantified as “real-world” outcomes? This rapid review examines these possibilities and the steps that may be required to examine this reliably.

Insurance-Mediated Disparities in Gynecologic Oncology Care

Insurance coverage has lagged behind improvements in gynecologic cancer care, with one third of women never seeing a gynecologic oncologist and half experiencing financial toxicity during cancer treatment.

With 102,000 new cases of gynecologic cancer, 30,000 associated deaths annually, and increasing rates of endometrial cancer, gynecologic cancer is a growing problem. Although gynecologic cancer care has advanced significantly in the past decade owing to new therapeutics and specialized training in radical surgery, even insured women face major barriers to accessing and affording quality gynecologic cancer care. This commentary reviews current literature on insurance-mediated disparities in gynecologic cancer and provides education to clinicians on barriers to care. One third of women with a gynecologic cancer never see a gynecologic oncologist. Up to 40% of Medicare Advantage plans lack an in-network gynecologic oncologist, and 33% of private insurance plans do not include an in-network National Cancer Institute-accredited cancer center, limiting access to surgical advances and clinical trials. Women with Medicaid insurance and gynecologic cancer are 25% less likely to receive guideline-concordant care. Among insured women, 50% experience financial toxicity during gynecologic cancer treatment, and costs may be even higher for certain Medicare enrollees. Addressing these insurance-mediated disparities will be important to help our patients fully benefit from the scientific advances in our field and thrive after a gynecologic cancer diagnosis.

Association of Treatment Intensity With Survival in Older Patients With Hodgkin Lymphoma

IMPORTANCE

Hodgkin lymphoma is an aggressive blood cancer that is highly curable in younger patients who receive multiagent chemotherapy. Worse survival in older patients may reflect less-aggressive treatment, competing risks of death, or different disease biological factors.

OBJECTIVE

To examine the association between treatment intensity and cause-specific mortality among older adults with Hodgkin lymphoma.

DESIGN, SETTING, AND PARTICIPANTS

This was a population-based cohort study of patients aged 65 years or older with Medicare Part A and B fee-for-service coverage who received a diagnosis of Hodgkin lymphoma from 2000 to 2013. The association between treatment intensity and cause-specific mortality was estimated separately for early-stage and advanced-stage disease with Cox proportional hazards models. Multivariable adjustment and propensity score weighting helped control for confounding. Data are from the 1999 to 2016 Surveillance, Epidemiology, and End Results Medicare database. Data analysis was performed from April 2020 to June 2021.

EXPOSURES

First-line treatment categorized as (1) full chemotherapy regimen, (2) partial chemotherapy regimen, (3) single chemotherapy agent or radiotherapy, or (4) no treatment.

MAIN OUTCOMES AND MEASURES

The main outcome was 3-year Hodgkin lymphoma-specific and other-cause mortality.

RESULTS

Among 2686 patients (mean [SD] age, 75.7 [6.9] years; 1333 men [50%]), 1307 had early-stage disease and 1379 had advanced-stage disease. For Hodgkin lymphoma-specific mortality in patients with early-stage disease, hazard ratios (HRs) were higher for partial regimens (HR, 1.77; 95% CI, 1.22-2.57) or no treatment (HR, 1.91; 95% CI, 1.31-2.79) than for full regimens; there was no difference between single-agent chemotherapy or radiotherapy and full regimens. For other-cause mortality in patients with early-stage disease, HRs were higher for partial regimens (HR, 1.69; 95% CI, 1.18-2.44), single-agent chemotherapy or radiotherapy (HR, 1.62; 95% CI, 1.13-2.33), or no treatment (HR, 2.71; 95% CI, 1.95-3.78) than for full regimens. For Hodgkin lymphoma-specific mortality in patients with advanced-stage disease, HRs were higher for partial regimens (HR, 3.26; 95% CI, 2.44-4.35), single-agent chemotherapy or radiotherapy (HR, 2.85; 95% CI, 1.98-4.11), or no treatment (HR, 4.06; 95% CI, 3.06-5.37) than for full regimens. For other-cause mortality in patients with advanced-stage disease, HRs were higher for partial regimens (HR, 1.76; 95% CI, 1.32-2.33), single-agent chemotherapy or radiotherapy (HR, 1.65; 95% CI, 1.15-2.37), or no treatment (HR, 2.24; 95% CI, 1.71-2.94) than for full regimens.

CONCLUSIONS AND RELEVANCE

This cohort study found variability in the magnitude of the association between treatment intensity and mortality by stage and cause-specific mortality, possibly reflecting competing risks of death. However, full chemotherapy regimens were associated with lower mortality and could be considered for older adults who can tolerate them.

Association of Genetic Testing Results with Mortality Among Women with Breast Cancer or Ovarian Cancer

BACKGROUND

Breast cancer and ovarian cancer patients increasingly undergo germline genetic testing. However, little is known about cancer-specific mortality among carriers of a pathogenic variant (PV) in BRCA1/2 or other genes in a population-based setting.

METHODS

Georgia and California Surveillance Epidemiology and End Results (SEER) registry records were linked to clinical genetic testing results. Women were included who had stages I-IV breast cancer or ovarian cancer diagnosed in 2013-2017; received chemotherapy; and linked to genetic testing results. Multivariable Cox proportional hazard models were used to examine the association of genetic results with cancer-specific mortality.

RESULTS

22,495 breast and 4,320 ovarian cancer patients were analyzed, with a median follow-up of 41 months. PVs were present in 12.7% of breast cancer patients with estrogen and/or progesterone receptor-positive, HER2-negative cancer, 9.8% with HER2-positive cancer, 16.8% with triple-negative breast cancer and 17.2% with ovarian cancer. Among triple-negative breast cancer patients, cancer-specific mortality was lower with BRCA1 (hazard ratio [HR] = 0.49, 95% confidence interval [CI] = 0.35-0.69) and BRCA2 PVs (HR = 0.60, 95% CI = 0.41-0.89), and equivalent with PVs in other genes (HR = 0.65, 95% CI = 0.37-1.13), versus non-carriers. Among ovarian cancer patients, cancer-specific mortality was lower with PVs in BRCA2 (HR = 0.35, 95% CI = 0.25-0.49) and genes other than BRCA1/2 (HR = 0.47, 95% CI = 0.32-0.69). No PV was associated with higher cancer-specific mortality.

CONCLUSIONS

Among breast cancer and ovarian cancer patients treated with chemotherapy in the community, BRCA1/2 and other gene PV carriers had equivalent or lower short-term cancer-specific mortality than non-carriers. These results may reassure newly diagnosed patients and longer follow-up is ongoing.

Impact of Radiation on Cardiovascular Outcomes in Older Resectable Esophageal Cancer Patients With Medicare

OBJECTIVES

Preoperative radiotherapy improves outcomes for operable esophageal cancer patients, though the proximity of the heart to the esophagus puts patients at risk of radiation-induced cardiovascular disease. This study characterizes the impact of radiotherapy and different radiation techniques on cardiovascular morbidity among a cohort of esophageal cancer patients.

MATERIALS AND METHODS

We identified 1125 patients aged 65 and older diagnosed between 2000 and 2011 with esophageal cancer who received surgery alone, or surgery preceded by either preoperative chemotherapy or preoperative chemoradiation from the Surveillance Epidemiology and End Results (SEER)-Medicare database. We used Medicare claims to identify severe perioperative and late cardiovascular events. Multivariable logistic regression and Fine-Gray models were used to determine the effect of presurgery treatment on the risk of perioperative and late cardiovascular disease.

RESULTS

Preoperative chemotherapy or chemoradiation did not significantly increase the risk of perioperative cardiovascular complications compared with surgery alone. Patients treated with preoperative chemoradiation had a 36% increased risk of having a late cardiovascular event compared with patients treated with surgery alone (subdistribution hazard ratio [SDHR]: 1.36; P=0.035). There was no significant increase in late cardiovascular events among patients treated with preoperative chemotherapy (SDHR: 1.18; P=0.40). Among patients treated with preoperative chemoradiation, those receiving intensity modulated radiotherapy had a 68% decreased risk of having a late cardiovascular event compared with patients receiving conventional radiation (SDHR: 0.32; P=0.007).

CONCLUSIONS

This study demonstrates an increased risk of cardiovascular complications among operative esophageal cancer patients treated with preoperative chemoradiation, though these risks might be reduced with more cardioprotective radiation techniques such as intensity modulated radiotherapy.

Systemic therapy, survival and end-of-life costs for metastatic triple-negative breast cancer: retrospective SEER-Medicare study of women age ≥65 years

Aim: To analyze therapy for metastatic triple-negative breast cancer (mTNBC), factors contributing to survival and costs. Patients & methods: Using 2010-2016 SEER-Medicare data, we identified women (≥65 years) with mTNBC. Results: Of 302 eligible patients, 152 (50%) received systemic therapy. In multivariable regression analyses, only age <75 years was associated with therapy receipt (odds ratio: 2.91; 95% CI: 1.79-4.74); and only systemic therapy significantly reduced risk of death (hazard ratio: 0.34; 95% CI: 0.26-0.44). Median overall survival was 13.4 (95% CI: 11.3-15.1) vs 3.3 months (95% CI: 2.7-3.9) in therapy vs no-therapy cohorts. Mean per-patient-per-month costs <30 days before end-of-life/follow-up were $14,100 and $15,600 (2019 USD), respectively. Conclusion: Poor outcomes and high costs indicate need for more effective mTNBC therapy.

Disparities in surgical management of endometrial cancers in a public healthcare system: A question of equity

OBJECTIVE

Timely surgery has been shown to impact outcome in endometrial cancer patients. Social determinants of health (SDH) are associated with adverse cancer outcomes. We sought to evaluate the association of SDH with surgical treatment indicators in endometrial cancer patients in a public healthcare system.

METHODS

Endometrial cancer patients in Ontario, Canada, diagnosed between 2009 and 2017 were identified, and clinical, social and demographic variables were extracted from administrative databases. Validated community marginalization scores that include material deprivation, residential instability and ethnic concentration were used for stratification. Surgical treatment features were compared across marginalization quintiles using chi-square, Fischer exact or Wilcoxon rank sum tests as appropriate. Predictors of timely surgical treatment were evaluated with logistic regression.

RESULTS

20228 patients were identified of whom 14,423 had primary hysterectomy for a preoperative diagnosis of endometrial cancer. Fewer patients in marginalized communities received surgery (89% vs. 93%, p < 0.001). Surgical delay was longer among marginalized patients and 78% had surgery within 12 weeks compared to 84% of those least marginalized (p < 0.0001). Other quality indicators of surgical treatment were not negatively associated with marginalization. On multivariable analysis adjusted for patient and disease factors, marginalization was independently associated with increased odds of delayed surgery (OR = 0.94/quintile, CI 0.91-0.97, p < 0.001).

CONCLUSIONS

Social marginalization is associated with decreased likelihood of having surgery and with delayed surgery among endometrial cancer patients in Ontario. This may be mediated by delayed presentation and real or perceived barriers to access. Reducing surgical wait times among marginalized cancer patients is an important deliverable in public healthcare.

First-line treatment in older patients with Hodgkin lymphoma: a Surveillance, Epidemiology, and End Results (SEER)-Medicare population-based study

While Hodgkin lymphoma (HL) is highly curable in younger patients, older patients have higher relapse and death rates, which may reflect age-related factors, distinct disease biology and/or treatment decisions. We described the association between patient, disease and geographic factors and first-line treatment in older patients (≥65 years) with incident HL using Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 1999 to 2014 (n = 2825). First-line treatment initiated at ≤4 months after diagnosis was categorised as: full chemotherapy regimen (n = 699, 24·7%); partial chemotherapy regimen (n = 1016, 36·0%); single chemotherapy agent or radiotherapy (n = 382, 13·5%); and no treatment (n = 728, 25·8%). Among the fully treated, ABVD [doxorubicin (Adriamycin), bleomycin, vinblastine, dacarbazine]/AVD was most common (n = 635, 90·8%). Adjusted multinomial logistic regression identified factors associated with treatment. Older age, Medicaid dual eligibility, not married, frailty, cardiac comorbidity, prior cancer, earlier diagnosis date, histology, advanced disease Stage, B symptoms and South region were independently associated with increased odds of not receiving full chemotherapy regimens. In conclusion, we found variability in first-line HL treatment for older patients. Treatment differences by Medicaid and region may indicate disparities. Even after adjusting for frailty and cardiac comorbidity, age was associated with treatment, suggesting factors such as end-of-life care or shared decision-making may influence treatment in older patients.

Advanced stage primary mucinous ovarian carcinoma. Where do we stand ?

OBJECTIVE

To evaluate factors associated with survival of patients with advanced stage mucinous ovarian carcinoma (MOC) using a large multi-institutional database.

METHODS

Patients diagnosed between 2004 and 2014 with advanced stage (III-IV) MOC were identified within the National Cancer Database. Those without a personal history of another primary tumor who received cancer-directed surgery with a curative intent were selected for further analysis. Overall survival (OS) was evaluated with Kaplan-Meier curves, and compared with the log-rank test. Multivariate Cox analysis was performed to identify independent predictors of survival.

RESULTS

A total of 1509 patients with a median age of 59 years (IQR 20) met the inclusion criteria: stage III (n = 1045, 69.3%) and stage IV disease (n = 464, 30.7%). Patients who received chemotherapy (n = 1065, 70.6%) had better OS compared to those who did not (n = 385, 25.5%), (median OS 15.44 vs 5.06 months, p < 0.001). The type of reporting facility (p = 0.65) and the year of diagnosis (p = 0.27) were not associated with OS. Presence of residual disease was strongly associated with OS (p < 0.001). After controlling for confounders, the administration of chemotherapy (HR 0.63, 95% CI 0.55, 0.72) was associated with better survival.

CONCLUSION

Advanced stage MOC has an extremely poor prognosis. Patients who received chemotherapy had a small improvement in survival. Every effort to achieve complete gross resection should be performed. Given no improvement in survival outcomes over time, there is an eminent need for novel treatment options.

Nonadherence to Standard of Care for Locally Advanced Colon Cancer as a Contributory Factor for High Mortality Rates in Kentucky

BACKGROUND

Kentucky has one of the highest mortality rates for colon cancer, despite dramatic improvements in screening. The National Comprehensive Cancer Network (NCCN) guidelines recommend operation and adjuvant chemotherapy for locally advanced (stage IIb/c and stage III) colon cancer (LACC). The purpose of this study was to determine the rate of nonadherence with current standard of care (SOC) and associated factors as possible contributors to mortality.

METHODS

The Kentucky Cancer Registry database linked with administrative health claims was queried for individuals (20 years and older) diagnosed with LACC from 2007 to 2012. Bivariate and logistic regression of nonadherence was performed. Survival analysis was performed with Cox regression and Kaplan-Meier plots.

RESULTS

A total of 1,404 patients with LACC were included. Approximately 42% of patients with LACC were noted to be nonadherent to SOC, with nearly all (95.7%) failing to receive adjuvant chemotherapy. After adjusting for all significant factors, we found the factors associated with nonadherence included the following: age older than 75 years, stage III colon cancer, high Charlson Comorbidity Index (3+), low poverty level, Medicaid coverage, and disability. Adherence to SOC is associated with a significant improvement in the 5-year survival rate compared with nonadherence (63.0% and 27.4%, respectively; p < 0.0001).

CONCLUSIONS

Our study identified multiple factors associated with the failure of patients with LACC to receive SOC, particularly adjuvant chemotherapy, suggesting the need to focus on improving adjuvant chemotherapy compliance in specific populations. Nonadherence to LACC SOC is likely a major contributor to the persistently high mortality rates in Kentucky.

Mediation analyses of socioeconomic factors determining racial differences in the treatment of diffuse large B-cell lymphoma in a cohort of older adults

Despite near universal health coverage under Medicare, racial disparities persist in the treatment of diffuse large B-cell lymphoma (DLBCL) among older patients in the United States. Studies evaluating DLBCL outcomes often treat socioeconomic status (SES) measures as confounders, potentially introducing biases when SES factors are mediators of disparities in cancer treatment.To examine differences in DLBCL treatment, we performed causal mediation analyses of SES measures, including: metropolitan statistical area (MSA) of residence; census-tract poverty level; and private Medicare supplementation using the Surveillance, Epidemiology and End Results-Medicare linked database between 2001 and 2011. In this retrospective cohort study of DLBCL patients ages 66+ years, we conducted a series of multivariable logistic regression analyses estimating odds ratios (OR) and 95% confidence intervals (CI) relating chemo- and/or immuno-therapy treatment and each SES measure, comparing non-Hispanic (NH)-black, Hispanic/Latino, and Asian/Pacific Islander (API) to NH-white patients.Compared to NH-white patients, racial/ethnic minority patients had lower odds of receiving chemo- and/or immuno-therapy treatment (NH-black: OR 0.84, 95% CI 0.65, 1.08; API: OR 0.80, 95% CI 0.64, 1.01; Hispanic/Latino: OR 0.78, 95% CI 0.64, 0.96) and higher odds of lacking private Medicare supplementation and residence within an urban MSA and poor census tracts. Adjustment for SES measures as confounders nullified observed racial differences. In causal mediation analyses, between 31% and 38% of race/ethnicity differences were mediated by having private Medicare supplementation.Providing equitable access to Medicare supplementation may reduce disparities in receipt of chemo- and/or immuno-therapy treatment in older DLBCL patients.

Care experiences among dually enrolled older adults with cancer: SEER-CAHPS, 2005-2013

PURPOSE

Given the associations between poverty and poorer outcomes among older adults with cancer, we sought to understand the effects of dual enrollment in Medicare and Medicaid-as a marker of poverty-on self-reported care experiences among seniors diagnosed with cancer.

METHODS

Retrospective, observational study using cancer registry, Medicare claims, and care experience survey data (Surveillance, Epidemiology, and End Results [SEER]-Consumer Assessment of Healthcare Providers and Systems [CAHPS®]) for a national sample of fee-for-service (FFS) and Medicare Advantage (MA) enrollees aged 65 or older. We included people with one incident primary, malignant cancer diagnosed between 2005 and 2011, surveyed within 2 years after diagnosis (n = 9,800; 995 dual enrollees). Medicare CAHPS measures included 5 global ratings and 3 composite scores.

RESULTS

After adjustment for potential confounders, people with cancer histories who were dually enrolled were significantly more likely to report better experiences than non-duals on 2 measures (Medicare/their health plan: adjusted odds ratio [aOR]: 0.68, 95% confidence interval [CI] 0.53-0.87; prescription drug plan [PDP]: aOR: 0.54, 95% CI 0.40-0.73).

CONCLUSIONS

Dual enrollees with cancer reported better experiences than Medicare-only enrollees in terms of their health plan (Medicare FFS or Medicare Advantage) and their PDP. Better ratings among dually enrolled beneficiaries suggest possible divergence between health outcomes and care experiences, warranting additional investigation.

Prevalence, Predictors, and Implications for Appropriate Use of Active Surveillance Management Among Black Men Diagnosed With Low-risk Prostate Cancer

BACKGROUND

Consensus guidelines recommend that active surveillance (AS) be considered in the management of men with low-risk prostate cancer (LRPC). The objective was to evaluate the prevalence and predictors of an AS approach in black men (BM) diagnosed with LRPC after inclusion of AS in LRPC consensus guidelines.

MATERIALS AND METHODS

BM and white men (WM) diagnosed with LRPC (prostate-specific antigen ≤10 ng/mL, Gleason score [GS] ≤6, clinical stage T1-T2a) between 2010 and 2013 were identified from the National Cancer Database. Logistic regression models were used to assess the likelihood of AS over time and to examine associations between sociodemographic characteristics (SDCs) and the receipt of AS. A subanalysis was performed to assess the likelihood of GS upgrading on prostatectomy specimens for cases that received definitive treatment with radical prostatectomy.

RESULTS

Overall, 9% of BM (N=15,242) with LRPC were managed with AS. The likelihood of BM undergoing AS increased from 2010 and for all subsequent years of the study period (P<0.001). Uninsured BM were twice as likely as those with private insurance to undergo AS (odds ratio [OR]=1.97; 95% confidence interval [CI], 1.51-2.58; P<0.001). BM were less likely than WM (N=86,655) to receive AS (OR=0.82; 95% CI, 0.77-0.87; P<0.001). However, on multivariate analysis adjusted for SDCs, there was no significant difference in AS utilization between the 2 race groups. Nearly half of BM (47.5%) treated with radical prostatectomy had a postprostatectomy GS≥7, and BM were 17% more likely to experience postprostatectomy upgrading to GS≥7 when compared with WM (OR=1.17; 95% CI, 1.08-1.26; P<0.001).

CONCLUSIONS

The utilization of AS for BM with LRPC seems to be increasing, is influenced by SDCs, and may not differ from AS utilization among WM. Careful consideration of prostate biopsy technique and sampling as well as SDCs at time of treatment planning may be necessary to ensure adequate evaluation of prostatic disease and appropriate disease management for BM with LRPC.

Disparities in Access to Sorafenib in Communities with Low Socioeconomic Status

OBJECTIVE

In the United States, hepatocellular carcinoma (HCC) is more common among communities with low socioeconomic status (SES), and these groups tend to be diagnosed with later-stage cancers. Sorafenib is the primary treatment for advanced HCC, however its substantial cost raises concern for access to treatment.

METHODS

The newly developed Case-Background method was used to estimate odds ratios for the impacts of various sociodemographic factors on sorafenib access in clinically eligible patients. Socioeconomic status was defined as a factor of median income and education level based on ZIP code of residence.

RESULTS

There was a strong association between sorafenib prescription and residence in an area of higher SES. While controlling for age, race/ethnicity, and insurance status, high SES residence doubled the odds of sorafenib prescription (OR=2.05, p&lt;.01).

CONCLUSIONS

Low socioeconomic status communities appear to have a reduced chance of receiving the only effective treatment for advanced HCC.

Disparities in Systemic Treatment Use in Advanced-stage Non-Small Cell Lung Cancer by Source of Health Insurance

BACKGROUND

Management of advanced-stage non-small cell lung cancer (NSCLC) has changed significantly over the past two decades with the development of numerous systemic treatments, including targeted therapies. However, a high proportion of advanced-stage patients are untreated. The role that health insurance plays in receipt of systemic treatments is unclear.

METHODS

Using California Cancer Registry data (2012-2014), we developed multivariable Poisson regression models to assess the independent effect of health insurance type on systemic treatment utilization among patients with stage IV NSCLC. Systemic treatment information was manually abstracted from treatment text fields.

RESULTS

A total of 17,310 patients were evaluated. Patients with Medicaid/other public insurance were significantly less likely to receive any systemic treatments [risk ratio (RR), 0.78; 95% confidence interval (CI), 0.75-0.82], bevacizumab combinations (RR, 0.57; 95% CI, 0.45-0.71), or tyrosine kinase inhibitors (RR, 0.70; 95% CI, 0.60-0.82) compared with the privately insured. Patients with Medicare or dual Medicare-Medicaid insurance were not significantly different from the privately insured in their likelihood of receiving systemic treatments.

CONCLUSIONS

Substantial disparities in the use of systemic treatments for stage IV NSCLC exist by source of health insurance in California. Patients with Medicaid/other public insurance were significantly less likely to receive systemic treatments compared with their privately insured counterparts.

IMPACT

Source of health insurance influences care received. Further research is warranted to better understand barriers to treatment that patients with Medicaid face.

Disparities in health-related quality of life in women undergoing treatment for advanced ovarian cancer: the role of individual-level and contextual social determinants

PURPOSE

Social determinants may influence health-related quality of life (HRQOL) among women with ovarian cancer, potentially creating disparities in clinical outcomes. We investigated the relationship between HRQOL and social determinants of health, including travel distance to access cancer care and health insurance type, among women participating in a randomized trial of primary adjuvant treatment for advanced ovarian cancer.

METHODS

The Functional Assessment of Cancer Therapy-Ovarian (FACT-O) questionnaire captured HRQOL (physical well-being, functional well-being, ovarian-specific, and trial outcome index [TOI]) prior to chemotherapy (baseline), during the trial, and 84 weeks after initiation of chemotherapy for women with advanced epithelial ovarian, primary peritoneal, or fallopian tube cancer. We constructed bivariate and multivariable linear mixed effects models examining the associations of social determinants of health (individual-level and contextual factors) with HRQOL scores at 84 weeks, clustering participants (n = 993) within treatment centers, and Census regions and controlling for baseline HRQOL.

RESULTS

Most individual-level (race, age, cancer stage, adverse events) and contextual (travel distance to treatment center, community socioeconomic status) factors were not statistically significantly associated with HRQOL. Compared to participants with private health insurance, other participants had lower mean HRQOL (physical well-being: public insurance, - 1.00 (standard error[SE] = 0.49) points, uninsured, - 1.93 (SE = 0.63) points; functional well-being: public, - 1.29 (SE = 0.59), uninsured, - 1.98 (SE = 0.76); ovarian cancer-specific: public, - 1.60 (SE = 0.59), uninsured, - 1.66 (SE = 0.75); TOI: public, - 3.81 (SE = 1.46), uninsured, - 5.51 (SE = 1.86); all p < .05).

CONCLUSIONS

Private health insurance was associated with improved HRQOL at the completion of treatment for advanced stage ovarian cancer. Implications of health insurance on HRQOL should be further investigated, particularly among women with ovarian cancer who receive standard of care treatment.

A contemporary framework of health equity applied to gynecologic cancer care: A Society of Gynecologic Oncology evidenced-based review

Health disparities are defined as the preventable difference in the burden of disease, injury, and violence, or opportunity to achieve optimal health that socially disadvantaged populations experience compared to the population as a whole. Disparities in incidence and cancer outcomes for women with gynecologic malignancies have been well described particularly for American women of Black race. The etiology of these disparities has been tied to socio-economics, cultural, educational and genetic factors. While access to high quality treatment has been primarily linked to survival from cervical and ovarian cancer, innate biologic distinctions have been principally cited as reasons for differences in incidence and mortality in cancers of the uterine corpus. This article will update the framework of disparities to incorporate a broader understanding of the social determinants of health and how they affect health equity by addressing the root causes of disparities within the health care system. Special populations are identified who are at risk for health inequities which include but are not limited to Black race, underserved racial and ethnic minorities (e.g. indigenous peoples, low English fluency), trans/gender nonconforming people and rural populations. Each of these populations at risk have unique structural barriers within the healthcare system impacting gynecologic cancer outcomes. The authors provide practical recommendations for practitioners aimed at eliminating cancer related outcome disparities.

A review of cancer outcomes among persons dually enrolled in Medicare and Medicaid

The fragmentation and lack of coordination of health care may result in less efficient and more costly care and lead to poorer outcomes. There has been increasing interest in examining cancer outcomes among persons who are dually enrolled in Medicare and Medicaid. Previous studies have identified disparities in the quality of cancer treatment according to race, ethnicity, socioeconomic status, and source of health insurance. This article, which is based upon bibliographic searches in PubMed, reviews the literature on dual enrollment in Medicare and Medicaid and cancer survival and quality of cancer treatment. A total of 65 articles were identified. Of the 65 articles that were screened using the full texts or abstracts, 13 studies met the eligibility criteria, one cross-sectional study and 12 cohort studies. The results of this systematic review indicate that there is only limited evidence that dual enrollment in Medicare and Medicaid is associated with poorer survival or quality of cancer care. The number of studies that have looked for associations between dual Medicare-Medicaid status and survival and quality of cancer treatment is still small. Outcomes and cancer site(s) varied among the studies. Additional studies are needed to determine the replicability of findings reported to date. Of particular interest are studies of major forms of cancer (breast, prostate, lung, colorectal) that include adequate numbers of patients described by insurance status, race, comorbidity, stage, receipt of appropriate cancer therapy, and survival.

Chemotherapy Use, End-of-Life Care, and Costs of Care Among Patients Diagnosed With Stage IV Pancreatic Cancer

CONTEXT

For patients with metastatic cancer and limited life expectancy, potential benefits of chemotherapy must be balanced against harms to quality of life near death and increased out-of-pocket costs of care.

OBJECTIVES

To evaluate the association between chemotherapy use by patients with Stage IV pancreatic cancer and health care use and Medicare and out-of-pocket costs in the last 30 days of life.

METHODS

We conducted a retrospective cohort study of 3825 patients aged 66 years or older when diagnosed with Stage IV pancreatic cancer in 2006-2011, using the linked Surveillance, Epidemiology, and End Results-Medicare data. Using a propensity score matched sample, we examined associations between initiation of chemotherapy shortly after the metastatic diagnosis (and secondarily, continued chemotherapy use in the last 30 days of life) and health care use and costs (both Medicare payment and patient out-of-pocket costs) in the last 30 days of life.

RESULTS

Chemotherapy use was associated with increased rates of hospital admissions (45.0% vs. 29.2%, P < 0.001), emergency department visits (41.3% vs. 27.2%, P < 0.001), and death in a hospital (14.2% vs. 9.1%, P < 0.001); fewer days in hospice care (11.5 days vs. 15.7 days, P < 0.001); and more than 50% increase in patient out-of-pocket costs for care ($1311.5 vs. $841.0, P < 0.001) in the last 30 days of life. Among patients who initiated chemotherapy, more stark differences in these outcomes were found by whether patients received chemotherapy in the last 30 days of life.

CONCLUSION

Chemotherapy use among older patients diagnosed with metastatic pancreatic cancer was associated with substantially increased use of health care and higher patient out-of-pocket costs near death.

Effects of Transitioning to Medicare Part D on Access to Drugs for Medical Conditions among Dual Enrollees with Cancer

OBJECTIVES

To evaluate the impact of transitioning from Medicaid to Medicare Part D drug coverage on the use of noncancer treatments among dual enrollees with cancer.

METHODS

We leveraged a representative 5% national sample of all fee-for-service dual enrollees in the United States (2004-2007) to evaluate the impact of the removal of caps on the number of reimbursable prescriptions per month (drug caps) under Part D on 1) prevalence and 2) average days' supply dispensed for antidepressants, antihypertensives, and lipid-lowering agents overall and by race (white and black).

RESULTS

The removal of drug caps was associated with increased use of lipid-lowering medications (days' supply 3.63; 95% confidence interval [CI] 1.57-5.70). Among blacks in capped states, we observed increased use of lipid-lowering therapy (any use 0.08 percentage points; 95% CI 0.05-0.10; and days' supply 4.01; 95% CI 2.92-5.09) and antidepressants (days' supply 2.20; 95% CI 0.61-3.78) and increasing trends in antihypertensive use (any use 0.01 percentage points; 95% CI 0.004-0.01; and days' supply 1.83; 95% CI 1.25-2.41). The white-black gap in the use of lipid-lowering medications was immediately reduced (-0.09 percentage points; 95% CI -0.15 to -0.04). We also observed a reversal in trends toward widening white-black differences in antihypertensive use (level -0.08 percentage points; 95% CI -0.12 to -0.05; and trend -0.01 percentage points; 95% CI -0.02 to -0.01) and antidepressant use (-0.004 percentage points; 95% CI -0.01 to -0.0004).

CONCLUSIONS

Our findings suggest that the removal of drug caps under Part D had a modest impact on the treatment of hypercholesterolemia overall and may have reduced white-black gaps in the use of lipid-lowering and antidepressant therapies.

Adherence to treatment guidelines and survival for older patients with stage II or III colon cancer in Texas from 2001 through 2011

BACKGROUND

Treatment guidelines for colon cancer recommend colectomy with lymphadenectomy of at least 12 lymph nodes for patients with stage I to stage III disease as surgery adherence (SA) and adjuvant chemotherapy for individuals with stage III disease. Herein, the authors evaluated adherence to these guidelines among older patients in Texas with colon cancer and the associated survival outcomes.

METHODS

Using Texas Cancer Registry data linked with Medicare data, the authors included patients with AJCC stage II and III colon cancer who were aged ≥66 years and diagnosed between 2001 and 2011. SA and adjuvant chemotherapy adherence rates to treatment guidelines were estimated. The chi-square test, general linear regression, survival probability, and Cox regression were used to identify factors associated with adherence and survival.

RESULTS

The rate of SA increased from 47.2% to 84% among 6029 patients with stage II or stage III disease from 2001 to 2011, and the rate of adjuvant chemotherapy increased from 48.9% to 53.1% for patients with stage III disease during the same time period. SA was associated with marital status, tumor size, surgeon specialty, and year of diagnosis. Patient age, sex, marital status, Medicare state buy-in status, comorbidity status, and year of diagnosis were found to be associated with adjuvant chemotherapy. The 5-year survival probability for patients receiving guideline-concordant treatment was the highest at 87% for patients with stage II disease and was 73% for those with stage III disease. After adjusting for demographic and tumor characteristics, improved cancer cause-specific survival was associated with the receipt of stage-specific, guideline-concordant treatment for patients with stage II or stage III disease.

CONCLUSIONS

The adherence to guideline-concordant treatment among older patients with colon cancer residing in Texas improved over time, and was associated with better survival outcomes. Future studies should be focused on identifying interventions to improve guideline-concordant treatment adherence. Cancer 2018;124:679-87. © 2017 American Cancer Society.

A Phamacoeconomic Analysis of Personalized Dosing vs Fixed Dosing of Pembrolizumab in Firstline PD-L1-Positive Non-Small Cell Lung Cancer

Background

In October 2016, pembrolizumab became the new standard of care for firstline treatment of patients with metastatic non-small cell lung cancer (mNSCLC) whose tumors express programmed death ligand 1 in at least 50% of cells. The US Food and Drug Administration-recommended dose is 200 mg every three weeks. Multiple studies have demonstrated equivalent efficacy with weight-based doses between 2 mg/kg and 10 mg/kg. The objective of this study was to compare the economic impact of using personalized dosing (2 mg/kg) vs fixed dosing (200 mg) in the firstline setting of mNSCLC.

Methods

We performed a budget impact analysis from the US societal perspective to compare fixed dosing with personalized dosing. We calculated the target population and weight of patients who would be treated with pembrolizumab annually in the firstline setting. Using survival curves from the KEYNOTE 024 trial with Weibull extrapolation, we estimated the mean number of cycles that patients would receive. Using the Medicare average sales price, we calculated the difference in cost between personalized and fixed dosing.

Results

Our base case model demonstrates that the total annual cost of pembrolizumab with fixed dosing is US $3 440 127 429, and with personalized dosing it is US $2 614 496 846. The use of personalized dosing would lead to a 24.0% annual savings of US $825 630 583 in the United States.

Conclusions

Personalized dosing of pembrolizumab may have the potential to save approximately $0.825 billion annually in the United States, likely without impacting outcomes. This option should be considered for the firstline management of PD-L1-positive advanced lung cancer.

Metastatic Melanoma: Treatment and Survival in the US after the Introduction of Ipilimumab and Vemurafenib

INTRODUCTION

The 5-year survival of metastatic melanoma is < 18%. Historically, treatment options were limited. In 2011, 2 new agents were approved.

METHODS

We re-abstracted the medical records of a random sample (n = 520) of metastatic melanoma patients who had been diagnosed in 2011 and reported to population-based registries in the U.S. We also queried their treating physicians. Factors associated with treatment and survival were assessed using logistic and Cox proportional hazards regressions, respectively.

RESULTS

21.4% of patients received no treatment, 20.8% received ipilimumab and 57.5% of patients with BRAF-positive tumors received vemurafenib/dabrafenib. Receipt of ipilimumab was less likely among patients of 75 years or older (vs. < 55 years: odds ratio (OR) 0.32; 95% confidence interval (CI) 0.15-0.66) and patients without private/military insurance. 46.8% of patients received BRAF testing. Receipt of BRAF testing was less likely among patients of 65 years or more and uninsured patients (OR 0.22; 95% CI 0.07-0.65). Receipt of ipilimumab was associated with better survival during the first 18 months after diagnosis (hazard ratio (HR) 0.66; 95% CI 0.51-0.84) and vemurafenib/dabrafenib with better survival during the first 10 months after diagnosis (HR 0.51; 95% CI 0.36-0.73).

CONCLUSION

The initial dissemination of ipilimumab and vemurafenib/dabrafenib was limited. Additional research is needed to investigate the apparent lack of long-term survival benefit from these agents.

Survival Gains from First-Line Systemic Therapy in Metastatic Non-Small Cell Lung Cancer in the U.S., 1990-2015: Progress and Opportunities

BACKGROUND

Approximately 190,000 Americans are diagnosed with non-small cell lung cancer (NSCLC) annually, and about half have metastatic (Stage IV) disease. These patients have historically had poor survival prognosis, but several new therapies introduced since 2000 provide options for improved outcomes. The objectives of this study were to quantify survival gains from 1990, when best supportive care (BSC) only was standard, to 2015 and to estimate the impact of expanded use of systemic therapies in clinically appropriate patients.

MATERIALS AND METHODS

We developed a simulation model to estimate survival gains for patients with metastatic NSCLC from 1990-2015. Survival estimates were derived from major clinical trials and extrapolated to a lifetime horizon. Proportions of patients receiving available therapies were derived from the Surveillance, Epidemiology, and End Results database and a commercial treatment registry. We also estimated gains in overall survival (OS) in scenarios in which systemic therapy use increased by 10% and 30% relative to current use.

RESULTS

From 1990-2015, one-year survival proportion increased by 14.1% and mean per-patient survival improved by 4.2 months (32,700 population life years). Increasing treated patients by 10% or 30% increased OS by 5.1 months (39,700 population life years) and 6.9 months (53,800 population life years), respectively.

CONCLUSION

Although survival remains poor in metastatic NSCLC relative to other common cancers, meaningful progress in per-patient and population-level outcomes has been realized over the past 25 years. These advances can be improved even further by increasing use of systemic therapies in the substantial proportion of patients who are suitable for treatment yet who currently receive BSC only. The Oncologist 2017;22:304-310 IMPLICATIONS FOR PRACTICE: Approximately 93,500 Americans are diagnosed with metastatic non-small cell lung cancer (NSCLC) annually. Historically, these patients have had poor survival prognosis, but newer therapies provide options for improved outcomes. This simulation modeling study quantified metastatic NSCLC survival gains from 1990-2015. Over this period, the one-year survival proportion and mean per-patient survival increased by 14.1% and 4.2 months, respectively. Though metastatic NSCLC survival remains poor, the past 25 years have brought meaningful gains. Additional gains could be realized by increasing systemic therapy use in the substantial proportion of patients who are suitable for treatment, yet currently receive only supportive care.

Socioeconomic disparities, financial toxicity, and opportunities for enhanced system efficiencies for patients with cancer

Cancer care continues to stress the US healthcare system with increases in life expectancy, cancer prevalence, and survivors' complex needs. These challenges are compounded by socioeconomic, racial, and cultural disparities that are associated with poor clinical outcomes. One innovative and resource-wise strategy to address this demand on the system is expanded use of telehealth. This paradigm has the potential to decrease healthcare and patient out-of-pocket costs and improve patient adherence to recommended treatment and/or surveillance.

Underutilization of gene expression profiling for early-stage breast cancer in California

PURPOSE

To describe the utilization of gene expression profiling (GEP) among California breast cancer patients, identify predictors of use of GEP, and evaluate how utilization of GEP influenced treatment of early-stage breast cancer.

METHODS

All women diagnosed with hormone-receptor-positive, node-negative breast cancer reported to the California Cancer Registry between January 2008 and December 2010 were linked to Oncotype DX (ODX) assay results.

RESULTS

Overall, 26.7 % of 23,789 eligible patients underwent the assay during the study period. Women age 65 or older were much less likely than women under age 50 to be tested (15.1 vs. 41.4 %, p < 0.001). Black women were slightly less likely and Asian women were slightly more likely than non-Hispanic white women to undergo GEP with the ODX assay (22.2 and 28.9 vs. 26.9 %, respectively, p < 0.001). Patients residing in low SES census tracts had the lowest use of the test (8.9 %), with the proportion increasing with higher SES category. Women with Medicaid health insurance were less likely than other women to be tested (17.7 vs. 27.5 %, p < 0.001). Receipt of adjuvant chemotherapy (ACT) was associated with the ODX recurrence score, although only 63 % of patients whose recurrence scores indicated a high benefit received ACT. Of patients not tested, 15 % received ACT.

CONCLUSIONS

Nearly three-fourths of eligible breast cancer patients in California during the 3-year period 2008 through 2010 did not undergo GEP. As a result, it is likely that many women unnecessarily received ACT and suffered associated morbidity. In addition, some high-risk women who would have benefited most from ACT were not identified.

Annual Medical Expenditure and Productivity Loss Among Colorectal, Female Breast, and Prostate Cancer Survivors in the United States

BACKGROUND

There are limited nationally representative estimates of the annual economic burden among survivors of the three most prevalent cancers (colorectal, female breast, and prostate) in both nonelderly and elderly populations in the United States.

METHODS

The 2008 to 2012 Medical Expenditure Panel Survey data were used to identify colorectal (n = 540), female breast (n = 1568), and prostate (n = 1170) cancer survivors and individuals without a cancer history (n = 109 423). Excess economic burden attributable to cancer included per-person excess annual medical expenditures and productivity losses (employment disability, missed work days, and days stayed in bed). All analyses were stratified by cancer site and age (nonelderly: 18-64 years vs elderly: ≥ 65 years). Multivariable analyses controlled for age, sex, race/ethnicity, marital status, education, number of comorbidities, and geographic region. All statistical tests were two-sided.

RESULTS

Compared with individuals without a cancer history, cancer survivors experienced annual excess medical expenditures (for the nonelderly population, colorectal: $8647, 95% confidence interval [CI] = $4932 to $13 974, P < .001; breast: $5119, 95% CI = $3439 to $7158, P < .001; prostate: $3586, 95% CI = $1792 to $6076, P < .001; for the elderly population, colorectal: $4913, 95% CI = $2768 to $7470, P < .001; breast: $2288, 95% CI = $814 to $3995, P = .002; prostate: $3524, 95% CI = $1539 to $5909, P < .001). Nonelderly colorectal and breast cancer survivors experienced statistically significant annual excess employment disability (13.6%, P < .001, and 4.8%, P = .001) and productivity loss at work (7.2 days, P < .001, and 3.3 days, P = .002) and at home (4.5 days, P < .001, and 3.3 days, P = .003). In contrast, elderly survivors of all three cancer sites had comparable productivity losses as those without a cancer history.

CONCLUSIONS

Colorectal, breast, and prostate cancer survivors experienced statistically significantly higher economic burden compared with individuals without a cancer history; however, excess economic burden varies by cancer site and age. Targeted efforts will be important in reducing the economic burden of colorectal, breast, and prostate cancer.

Colon cancer care and survival: income and insurance are more predictive in the USA, community primary care physician supply more so in Canada

BACKGROUND

Our research group advanced a health insurance theory to explain Canada's cancer care advantages over America. The late Barbara Starfield theorized that Canada's greater primary care-orientation also plays a critically protective role. We tested the resultant Starfield-Gorey theory by examining the effects of poverty, health insurance and physician supplies, primary care and specialists, on colon cancer care in Ontario and California.

METHODS

We analyzed registry data for people with non-metastasized colon cancer from Ontario (n = 2,060) and California (n = 4,574) diagnosed between 1996 and 2000 and followed to 2010. We obtained census tract-based socioeconomic data from population censuses and data on county-level physician supplies from national repositories: primary care physicians, gastroenterologists and other specialists. High poverty neighborhoods were oversampled and the criterion was 10 year survival. Hypotheses were explored with standardized rate ratios (RR) and tested with logistic regression models.

RESULTS

Significant inverse associations of poverty (RR = 0.79) and inadequate health insurance (RR = 0.80) with survival were observed in the California, while they were non-significant or non-existent in Ontario. The direct associations of primary care physician (RRs of 1.32 versus 1.11) and gastroenterologist (RRs of 1.56 versus 1.15) supplies with survival were both stronger in Ontario than California. The supply of primary care physicians took precedence. Probably mediated through the initial course of treatment, it largely explained the Canadian advantage.

CONCLUSIONS

Poverty and health insurance were more predictive in the USA, community physician supplies more so in Canada. Canada's primary care protections were greatest among the most socioeconomically vulnerable. The protective effects of Canadian health care prior to enactment of the Affordable Care Act (ACA) clearly suggested the following. Notwithstanding the importance of insuring all, strengthening America's system of primary care will probably be the best way to ensure that the ACA's full benefits are realized. Finally, Canada's strong primary care system ought to be maintained.