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Aminpour N, Phan V, Wang H, McDermott J, Valentin M, Mishra A, DeLia D, Noel M, Al-Refaie W. Clinician-to-clinician connectedness and access to gastric cancer surgery at National Cancer Institute-designated cancer centers. J Gastrointest Surg 2024:S1091-255X(24)00480-3. [PMID: 38910084 DOI: 10.1016/j.gassur.2024.05.028] [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: 03/31/2024] [Revised: 05/16/2024] [Accepted: 05/26/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND For patients with gastric cancer, the pathway from primary care (PC) clinician to gastroenterologist to cancer specialist (medical oncologist or surgeons) is referral dependent. The impact of clinician connectedness on disparities in quality gastric cancer care, such as at National Cancer Institute-designated cancer centers (NCI-CC), remains underexplored. This study evaluated how clinician connectedness influences access to gastrectomy at NCI-CC. METHODS Maryland's All-Payer Claims Database was used to evaluate 667 patients who underwent gastrectomy for cancer from 2013 to 2018. Two separate referral linkages, defined as ≥9 shared patients, were examined: (1) PC clinicians to gastroenterologists at NCI-CC and (2) gastroenterologists to cancer specialists at NCI-CC. Multiple logistic regression models determined associations between referral linkages and odds of undergoing gastrectomy at NCI-CC. RESULTS Only 15% of gastrectomies were performed at NCI-CC. Patients of gastroenterologists with referral links to cancer specialists at NCI-CC were more likely to be <65 years, male, White, and privately insured. Every additional referral link between PC clinician and gastroenterologist at NCI-CC and between gastroenterologist and cancer specialist at NCI-CC increased the odds of gastrectomy at NCI-CC by 71% and 26%, respectively. Black patients had half the odds as White patients in receiving gastrectomy at NCI-CC; however, adjusting for covariates including clinician-to-clinician connectedness attenuated this observation. CONCLUSION Patients of clinicians with low connectedness and Black patients are less likely to receive gastrectomy at NCI-CC. Enhancing clinician connectedness is necessary to address disparities in cancer care. These results are relevant to policy makers, clinicians, and patient advocates striving for health equity.
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Affiliation(s)
- Nathan Aminpour
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, United States
| | - Vy Phan
- Georgetown University School of Medicine, Washington, DC, United States
| | - Haijun Wang
- MedStar Health Research Institute, Hyattsville, MD, United States
| | - James McDermott
- Department of Surgery, Stanford University, Stanford, CA, United States
| | - Michelle Valentin
- Georgetown University School of Medicine, Washington, DC, United States
| | - Ankit Mishra
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Derek DeLia
- Bloustein School of Planning and Public Policy, Rutgers University, New Brunswick, NJ, United States
| | - Marcus Noel
- Department of Medicine, MedStar-Georgetown University Hospital, Washington, DC, United States
| | - Waddah Al-Refaie
- Department of Surgery, Creighton University School of Medicine and CHI Health, Omaha, NE, United States.
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Sabik LM, Kwon Y, Drake C, Yabes J, Bhattacharya M, Sun Z, Bradley CJ, Jacobs BL. Impact of the Affordable Care Act on access to accredited facilities for cancer treatment. Health Serv Res 2024. [PMID: 38698670 DOI: 10.1111/1475-6773.14315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2024] Open
Abstract
OBJECTIVE To examine differential changes in receipt of surgery at National Cancer Institute (NCI)-designated comprehensive cancer centers (NCI-CCC) and Commission on Cancer (CoC) accredited hospitals for patients with cancer more likely to be newly eligible for coverage under Affordable Care Act (ACA) insurance expansions, relative to those less likely to have been impacted by the ACA. DATA SOURCES AND STUDY SETTING Pennsylvania Cancer Registry (PCR) for 2010-2019 linked with discharge records from the Pennsylvania Health Care Cost Containment Council (PHC4). STUDY DESIGN Outcomes include whether cancer surgery was performed at an NCI-CCC or a CoC-accredited hospital. We conducted a difference-in-differences analysis, estimating linear probability models for each outcome that control for residence in a county with above median county-level pre-ACA uninsurance and the interaction between county-level baseline uninsurance and cancer treatment post-ACA to capture differential changes in access between those more and less likely to become newly eligible for insurance coverage (based on area-level proxy). All models control for age, sex, race and ethnicity, cancer site and stage, census-tract level urban/rural residence, Area Deprivation Index, and year- and county-fixed effects. DATA COLLECTION/EXTRACTION METHODS We identified adults aged 26-64 in PCR with prostate, lung, or colorectal cancer who received cancer-directed surgery and had a corresponding surgery discharge record in PHC4. PRINCIPAL FINDINGS We observe a differential increase in receiving care at an NCI-CCC of 6.2 percentage points (95% CI: 2.6-9.8; baseline mean = 9.8%) among patients in high baseline uninsurance areas (p = 0.001). Our estimate of the differential change in care at the larger set of CoC hospitals is positive (3.9 percentage points [95% CI: -0.5-8.2; baseline mean = 73.7%]) but not statistically significant (p = 0.079). CONCLUSIONS Our findings suggest that insurance expansions under the ACA were associated with increased access to NCI-CCCs.
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Affiliation(s)
- Lindsay M Sabik
- University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Youngmin Kwon
- University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Coleman Drake
- University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Jonathan Yabes
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Zhaojun Sun
- University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Cathy J Bradley
- Colorado School of Public Health and University of Colorado Cancer Center, Aurora, Colorado, USA
| | - Bruce L Jacobs
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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3
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Erfani P, Uppal N, Lam MB. Accreditation Standards-An Untapped Lever for Cancer Equity. JAMA Oncol 2024; 10:429-430. [PMID: 38386328 DOI: 10.1001/jamaoncol.2023.6811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
This Viewpoint describes how the Commission on Cancer and the National Cancer Institute can incorporate health equity benchmarks into existing standards to improve care and outcomes for all patients with cancer.
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Affiliation(s)
- Parsa Erfani
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nishant Uppal
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Miranda B Lam
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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4
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Williams CP, Deng L, Caston NE, Gallagher K, Angove R, Pisu M, Azuero A, Arend R, Rocque GB. Understanding the financial cost of cancer clinical trial participation. Cancer Med 2024; 13:e7185. [PMID: 38629264 PMCID: PMC11022148 DOI: 10.1002/cam4.7185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/14/2024] [Accepted: 03/29/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Though financial hardship is a well-documented adverse effect of standard-of-care cancer treatment, little is known about out-of-pocket costs and their impact on patients participating in cancer clinical trials. This study explored the financial effects of cancer clinical trial participation. METHODS This cross-sectional analysis used survey data collected in December 2022 and May 2023 from individuals with cancer previously served by Patient Advocate Foundation, a nonprofit organization providing social needs navigation and financial assistance to US adults with a chronic illness. Surveys included questions on cancer clinical trial participation, trial-related financial hardship, and sociodemographic data. Descriptive and bivariate analyses were conducted using Cramer's V to estimate the in-sample magnitude of association. Associations between trial-related financial hardship and sociodemographics were estimated using adjusted relative risks (aRR) and corresponding 95% confidence intervals (CI) from modified Poisson regression models with robust standard errors. RESULTS Of 650 survey respondents, 18% (N = 118) reported ever participating in a cancer clinical trial. Of those, 47% (n = 55) reported financial hardship as a result of their trial participation. Respondents reporting trial-related financial hardship were more often unemployed or disabled (58% vs. 43%; V = 0.15), Medicare enrolled (53% vs. 40%; V = 0.15), and traveled >1 h to their cancer provider (45% vs. 17%; V = 0.33) compared to respondents reporting no hardship. Respondents who experienced trial-related financial hardship most often reported expenses from travel (reported by 71% of respondents), medical bills (58%), dining out (40%), or housing needs (40%). Modeling results indicated that respondents traveling >1 h vs. ≤30 min to their cancer provider had a 2.2× higher risk of financial hardship, even after adjusting for respondent race, income, employment, and insurance status (aRR = 2.2, 95% CI 1.3-3.8). Most respondents (53%) reported needing $200-$1000 per month to compensate for trial-related expenses. Over half (51%) of respondents reported less willingness to participate in future clinical trials due to incurred financial hardship. Notably, of patients who did not participate in a cancer clinical trial (n = 532), 13% declined participation due to cost. CONCLUSION Cancer clinical trial-related financial hardship, most often stemming from travel expenses, affected almost half of trial-enrolled patients. Interventions are needed to reduce adverse financial participation effects and potentially improve cancer clinical trial participation.
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Affiliation(s)
| | - Luqin Deng
- University of Alabama at BirminghamBirminghamAlabamaUSA
| | | | | | | | - Maria Pisu
- University of Alabama at BirminghamBirminghamAlabamaUSA
| | - Andres Azuero
- University of Alabama at BirminghamBirminghamAlabamaUSA
| | - Rebecca Arend
- University of Alabama at BirminghamBirminghamAlabamaUSA
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5
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Rodriguez NJ, Ricker C, Stoffel EM, Syngal S. Barriers and Facilitators to Genetic Education, Risk Assessment, and Testing: Considerations on Advancing Equitable Genetics Care. Gastroenterology 2023; 164:5-8. [PMID: 36529467 PMCID: PMC11009722 DOI: 10.1053/j.gastro.2022.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Nicolette Juliana Rodriguez
- Division of Gastroenterology, Brigham and Women's Hospital, Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Charité Ricker
- Norris Comprehensive Cancer Center, Division of Medical Oncology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Elena M Stoffel
- Division of Gastroenterology, Department of Internal Medicine, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Sapna Syngal
- Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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6
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Rodriguez NJ, Ricker C, Stoffel EM, Syngal S. Barriers and Facilitators to Genetic Education, Risk Assessment, and Testing: Considerations on Advancing Equitable Genetics Care. Clin Gastroenterol Hepatol 2023; 21:3-7. [PMID: 36549838 PMCID: PMC10609510 DOI: 10.1016/j.cgh.2022.10.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Nicolette Juliana Rodriguez
- Division of Gastroenterology, Brigham and Women's Hospital, Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Charité Ricker
- Norris Comprehensive Cancer Center, Division of Medical Oncology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Elena M Stoffel
- Division of Gastroenterology, Department of Internal Medicine, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Sapna Syngal
- Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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7
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Wu J, Moss H. Financial Toxicity in the Post-Health Reform Era. J Am Coll Radiol 2023; 20:10-17. [PMID: 36509218 DOI: 10.1016/j.jacr.2022.09.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/21/2022] [Accepted: 09/27/2022] [Indexed: 12/13/2022]
Abstract
The Patient Protection and Affordable Care Act (ACA), enacted in March 2010, was comprehensive health care reform legislation aimed to improve health care access and quality of care and curb health care-related costs. This review focuses on key provisions of the ACA and their impact on financial toxicity. We will focus our review on cancer care, because this is the most commonly studied disease process in respect to financial toxicity. Patients with cancer face rising expenditures and financial burden, which in turn impact quality of life, compliance to treatment, and survival outcomes. Health insurance expansion include dependent-coverage expansion, Medicaid expansion, and establishment of the Marketplace. Coverage reform focused on reducing financial barriers by limiting cost sharing. Payment reforms included new innovative payment and delivery systems to focus on improving outcomes and reducing costs. Challenges remain as efforts to reduce costs have led to the expansion of insurance plans, such as high-deductible health plans, that may ultimately worsen financial toxicity in cancer and high out-of-pocket costs for further diagnostic testing and procedures. Further research is necessary to evaluate the long-term impacts of the ACA provisions-and threats to the ACA-on outcomes and the costs accrued by patients.
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Affiliation(s)
- Jenny Wu
- Resident, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina.
| | - Haley Moss
- Assistant Professor, Division of Gynecologic Oncology, Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
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8
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Williams CP, Geiger AM, Norton WE, de Moor JS, Everson NS. Influence of Cost-Related Considerations on Clinical Trial Participation: Results from the 2020 Health Information National Trends Survey (HINTS). J Gen Intern Med 2022; 38:1200-1206. [PMID: 36451016 PMCID: PMC9713084 DOI: 10.1007/s11606-022-07801-0] [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: 04/19/2022] [Accepted: 09/08/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND People experiencing financial burden are underrepresented in clinical trials. OBJECTIVE Describe the prevalence of cost-related considerations influential to trial participation and their associations with person-level characteristics. DESIGN This cross-sectional study used and assessed how three cost-related considerations would influence the decision to participate in a hypothetical clinical trial. PARTICIPANTS A total of 3682 US adult respondents to the Health Information National Trends Survey MAIN MEASURES: Survey-weighted multivariable logistic regression estimated associations between respondent characteristics and odds of reporting cost-related considerations as very influential to participation. KEY RESULTS Among 3682 respondents, median age was 48 (IQR 33-61). Most were non-Hispanic White (60%), living comfortably or getting by on their income (74%), with ≥ 1 medical condition (61%). Over half (55%) of respondents reported at least one cost-related consideration as very influential to trial participation, including if usual care was not covered by insurance (reported by 42%), payment for participation (24%), or support for participation (24%). Respondents who were younger (18-34 vs. ≥ 75, adjusted odds ratio [aOR] 4.3, 95% CI 2.3-8.1), more educated (high school vs. <high school, aOR 2.1, 95% CI 1.1-4.1), or with lower perceived income (having difficulty vs. living comfortably, aOR 2.1, 95% CI 1.1-3.8) had higher odds of reporting any cost-related consideration as very influential to trial participation. Non-Hispanic Black vs. non-Hispanic White respondents had 29% lower odds (95% CI 0.5-0.9) of reporting any cost-related consideration as very influential to trial participation. CONCLUSIONS Cost-related considerations would influence many individuals' decisions to participate in a clinical trial, though prevalence of these concerns differed by respondent characteristics. Reducing financial barriers to trial participation may promote equitable trial access and greater trial enrollment diversity.
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Affiliation(s)
- Courtney P Williams
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA.
| | - Ann M Geiger
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Wynne E Norton
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Janet S de Moor
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Nicole Senft Everson
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
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9
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Nguyen OT, McCormick R, Patel K, Reblin M, Kim L, Hume E, Powers B, Otto A, Alishahi Tabriz A, Islam J, Hong Y, Kirchhoff AC, Turner K. Health insurance literacy among head and neck cancer patients and their caregivers: A cross-sectional pilot study. Laryngoscope Investig Otolaryngol 2022; 7:1820-1829. [PMID: 36544972 PMCID: PMC9764792 DOI: 10.1002/lio2.940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/15/2022] [Accepted: 09/23/2022] [Indexed: 12/24/2022] Open
Abstract
Objective Health insurance literacy interventions may reduce financial burden and its effects on cancer patients and their caregivers. However, little is known about the health insurance literacy levels of head and neck cancer (HNC) patients and their caregivers. We assessed the feasibility of screening for health insurance literacy in a pilot study and described the health insurance literacy levels of HNC patients and their caregivers. Methods We administered a survey that assessed demographics and subjective and objective health insurance literacy to HNC patients and their caregivers. Subjective health insurance literacy was measured through the Health Insurance Literacy Measure (score range: 0-84). Objective health insurance literacy was measured through correct answers to a previously developed 10-question knowledge test. Due to a small sample size, inferential statistics were not used; we instead descriptively reported findings. Results The pilot included 48 HNC patients and 13 caregivers. About 44.4% of patients and 30.8% of caregivers demonstrated low health insurance literacy (HILM ≤60). On the 10-item knowledge test, patients had an average of 6.8 (SD: 2.3) correct responses and caregivers had 7.8 (SD: 1.1) correct responses. Calculating out-of-pocket costs for out-of-network services was challenging; only 9.5% of patients and 0% of caregivers answered correctly. Conclusion Additional outreach strategies may be needed to supplement screening for health insurance literacy. Areas of focus for interventions include improving understanding of how to calculate financial responsibility for health care services and filing an appeal for health insurance claim denial. Level of Evidence IV.
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Affiliation(s)
- Oliver T. Nguyen
- Department of Health Outcomes and BehaviorH. Lee Moffitt Cancer Center & Research InstituteTampaFloridaUSA
| | | | - Krupal Patel
- Department of Head and Neck OncologyH. Lee Moffitt Cancer Center & Research InstituteTampaFloridaUSA
| | - Maija Reblin
- Department of Family MedicineUniversity of VermontBurlingtonVermontUSA,Cancer Control & Population Health Sciences ProgramUniversity of Vermont Cancer CenterBurlingtonVermontUSA
| | - Lindsay Kim
- College of Medicine, University of South FloridaTampaFloridaUSA
| | - Emma Hume
- Department of Health Outcomes and BehaviorH. Lee Moffitt Cancer Center & Research InstituteTampaFloridaUSA
| | - Benjamin Powers
- Department of Gastrointestinal OncologyH. Lee Moffitt Cancer Center & Research InstituteTampaFloridaUSA
| | - Amy Otto
- Department of Public Health SciencesUniversity of MiamiCoral GablesFloridaUSA
| | - Amir Alishahi Tabriz
- Department of Health Outcomes and BehaviorH. Lee Moffitt Cancer Center & Research InstituteTampaFloridaUSA,Department of Gastrointestinal OncologyH. Lee Moffitt Cancer Center & Research InstituteTampaFloridaUSA,Department of Oncological SciencesUniversity of South FloridaTampaFloridaUSA
| | - Jessica Islam
- Department of Gastrointestinal OncologyH. Lee Moffitt Cancer Center & Research InstituteTampaFloridaUSA,Department of Cancer EpidemiologyH. Lee Moffitt Cancer Center & Research InstituteTampaFloridaUSA,Center for Immunization and Infection Research in CancerH. Lee Moffitt Cancer Center & Research InstituteTampaFloridaUSA
| | - Young‐Rock Hong
- Department of Health Services Research and ManagementUniversity of Florida College of Public Health and Health ProfessionsGainesvilleFloridaUSA
| | - Anne C. Kirchhoff
- Cancer Control and Population Sciences Research Program Huntsman Cancer Institute, University of UtahSalt Lake CityUtahUSA,Department of PediatricsUniversity of UtahSalt Lake CityUtahUSA
| | - Kea Turner
- Department of Health Outcomes and BehaviorH. Lee Moffitt Cancer Center & Research InstituteTampaFloridaUSA,Department of Gastrointestinal OncologyH. Lee Moffitt Cancer Center & Research InstituteTampaFloridaUSA,Department of Oncological SciencesUniversity of South FloridaTampaFloridaUSA
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10
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Smith GL, Banegas MP, Acquati C, Chang S, Chino F, Conti RM, Greenup RA, Kroll JL, Liang MI, Pisu M, Primm KM, Roth ME, Shankaran V, Yabroff KR. Navigating financial toxicity in patients with cancer: A multidisciplinary management approach. CA Cancer J Clin 2022; 72:437-453. [PMID: 35584404 DOI: 10.3322/caac.21730] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/15/2022] [Accepted: 04/13/2022] [Indexed: 12/21/2022] Open
Abstract
Approximately one-half of individuals with cancer face personal economic burdens associated with the disease and its treatment, a problem known as financial toxicity (FT). FT more frequently affects socioeconomically vulnerable individuals and leads to subsequent adverse economic and health outcomes. Whereas multilevel systemic factors at the policy, payer, and provider levels drive FT, there are also accompanying intervenable patient-level factors that exacerbate FT in the setting of clinical care delivery. The primary strategy to intervene on FT at the patient level is financial navigation. Financial navigation uses comprehensive assessment of patients' risk factors for FT, guidance toward support resources, and referrals to assist patient financial needs during cancer care. Social workers or nurse navigators most frequently lead financial navigation. Oncologists and clinical provider teams are multidisciplinary partners who can support optimal FT management in the context of their clinical roles. Oncologists and clinical provider teams can proactively assess patient concerns about the financial hardship and employment effects of disease and treatment. They can respond by streamlining clinical treatment and care delivery planning and incorporating FT concerns into comprehensive goals of care discussions and coordinated symptom and psychosocial care. By understanding how age and life stage, socioeconomic, and cultural factors modify FT trajectory, oncologists and multidisciplinary health care teams can be engaged and informative in patient-centered, tailored FT management. The case presentations in this report provide a practical context to summarize authors' recommendations for patient-level FT management, supported by a review of key supporting evidence and a discussion of challenges to mitigating FT in oncology care. CA Cancer J Clin. 2022;72:437-453.
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Affiliation(s)
- Grace L Smith
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew P Banegas
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California
| | - Chiara Acquati
- Graduate College of Social Work, University of Houston, Houston, Texas
- Department of Health Disparities Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shine Chang
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Fumiko Chino
- Department of Radiation Oncology, Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rena M Conti
- Department of Markets, Public Policy, and Law, Boston University School of Business, Boston, Massachusetts
| | - Rachel A Greenup
- Division of Surgical Oncology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Juliet L Kroll
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Margaret I Liang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Maria Pisu
- Department of Internal Medicine, The University of Alabama, Birmingham, Alabama
| | - Kristin M Primm
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael E Roth
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Veena Shankaran
- Seattle Cancer Care Alliance/University of Washington Medicine and Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - K Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
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11
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Insurance-Mediated Disparities in Gynecologic Oncology Care. Obstet Gynecol 2022; 139:305-312. [PMID: 34991133 PMCID: PMC8759538 DOI: 10.1097/aog.0000000000004643] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/28/2021] [Indexed: 11/26/2022]
Abstract
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.
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12
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Golla V, Kaye DR. The Impact of Health Delivery Integration on Cancer Outcomes. Surg Oncol Clin N Am 2021; 31:91-108. [PMID: 34776068 DOI: 10.1016/j.soc.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although integrated health care has largely been associated with increases in prices and static or decreased quality across many disease states, it has shown some successes in improving cancer care. However, its impact is largely equivocal, making consensus statements difficult. Critically, integration does not necessarily translate to clinical coordination, which might be the true driver behind the success of integrated health care delivery. Moving forward, it is important to establish payment models that support clinical care coordination. Shifting from a fragmented health system to a coordinated one may improve evidence-based cancer care, outcomes, and value for patients.
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Affiliation(s)
- Vishnukamal Golla
- Duke National Clinician Scholars Program, 200 Morris St, Suite 3400, DUMC Box 104427, Durham, NC 27701, USA; Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC, USA; Duke Cancer Institute, Durham, NC, USA; Duke-Margolis Policy Center; Durham Veterans Affairs Health Care System, Durham, NC, USA.
| | - Deborah R Kaye
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC, USA; Duke Cancer Institute, Durham, NC, USA; Duke-Margolis Policy Center
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13
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Nathan NH, Bakhsheshian J, Ding L, Mack WJ, Attenello FJ. Evaluating Medicaid expansion benefits for patients with cancer: National Cancer Database analysis and systematic review. J Cancer Policy 2021; 29:100292. [PMID: 35559947 PMCID: PMC8276859 DOI: 10.1016/j.jcpo.2021.100292] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/28/2021] [Accepted: 06/03/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Insurance status modifies healthcare access and inequities. The Affordable Care Act expanded Medicaid coverage for people with low incomes in the United States. This study assessed the consequences of this policy change for cancer care after expansion in 2014. METHODS National Cancer Database (NCDB) public benchmark reports were queried for each malignancy in 2013 and 2016. Furthermore, a systematic search [PubMed, Embase, Scopus and Cochrane] was performed. Data on insurance status, access to cancer screening and treatment, and socioeconomic disparities in these metrics was collected. RESULTS Two-tailed analysis of the NCDB revealed that 14 out of 18 eligible states had a statistically significant increase in Medicaid-insured patients with cancer after expansion. The average percentage increase was 51 % (13.2-204 %). From the systematic review, 229 studies were identified, 26 met inclusion. All 21 relevant articles reported lower uninsured rates. The average increase of Medicaid-insured patients was 77 % (9.5-230 %) and the average decrease of uninsured rates was 55 % (13.4-73 %). 15 out of 21 articles reported increased access to care. 16 out of 17 articles reported reductions in inequities. CONCLUSION Medicaid expansion in 2014 increased the number of insured patients with cancer. Expansion also improved access to screening and treatment in most oncologic care, and reduced socioeconomic disparities. Further studies evaluating correlative survival outcomes are needed. POLICY SUMMARY This study informs debates on expansion of Medicaid in state governments and electorates in the United States, and on health insurance reform broadly, by providing insight into how health insurance can benefit people with cancer while revealing how less insurance coverage could harm patients with cancer before and after their diagnosis. This study also contributes to discussions of health insurance mandates, subsidized coverage for people with low incomes, and covered healthcare services determinations by public and private health insurance providers in other countries.
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Affiliation(s)
- Neal H Nathan
- Keck School of Medicine, University of Southern California, 1975 Zonal Avenue, Los Angeles, CA, 90033, USA.
| | - Joshua Bakhsheshian
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, 1200 North State Street, Suite 3300, Los Angeles, CA, 90033, USA.
| | - Li Ding
- Department of Preventative Medicine, Keck School of Medicine, University of Southern California, 2001 North Soto Street, Los Angeles, CA, 90032, USA.
| | - William J Mack
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, 1200 North State Street, Suite 3300, Los Angeles, CA, 90033, USA.
| | - Frank J Attenello
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, 1200 North State Street, Suite 3300, Los Angeles, CA, 90033, USA.
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Keating NL. Higher Prices for Cancer Surgery at National Cancer Institute-Designated Cancer Centers-Are Payers Achieving Value for Their Dollars? JAMA Netw Open 2021; 4:e2119716. [PMID: 34342654 DOI: 10.1001/jamanetworkopen.2021.19716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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15
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Merkhofer C, Chennupati S, Sun Q, Eaton KD, Martins RG, Ramsey SD, Goulart BHL. Effect of Clinical Trial Participation on Costs to Payers in Metastatic Non-Small-Cell Lung Cancer. JCO Oncol Pract 2021; 17:e1225-e1234. [PMID: 34375561 PMCID: PMC8360452 DOI: 10.1200/op.20.01092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 06/06/2021] [Accepted: 06/22/2021] [Indexed: 02/02/2023] Open
Abstract
PURPOSE The costs associated with clinical trial enrollment remain uncertain. We hypothesized that trial participation is associated with decreased total direct medical costs to health care payers in metastatic non-small-cell lung cancer. METHODS In this retrospective cohort study, we linked clinical data from electronic medical records to sociodemographic data from a cancer registry and claims data from Medicare and two private insurance plans. We used a difference-in-difference analysis to estimate mean per patient per month total direct medical costs for patients enrolled on a second-line (2L) trial versus patients receiving standard-of-care 2L systemic therapy. RESULTS Among 70 eligible patients, the difference-in-difference of mean per patient per month total direct medical costs between 2L trial participants and nonparticipants was -$6,663 (P = .01), for a mean savings of $45,308 per patient for the duration of 2L trial therapy. In a secondary analysis by primary insurance payer, this difference-in-difference was -$5,526 (P = .26) for patients with commercial insurance and -$7,432 (P = .01) for patients with Medicare. CONCLUSION Participation in a 2L trial was associated with a $6,663 per month cost savings to health care payers for the duration of trial participation. Further studies are necessary to elucidate differences in cost savings from trial participation for Medicare and commercial payers. If confirmed, these results support health care payer investment in programs to improve clinical trial access and enrollment.
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Affiliation(s)
- Cristina Merkhofer
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Shasank Chennupati
- Hutchinson Institute for Cancer Outcomes Research, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Qin Sun
- Hutchinson Institute for Cancer Outcomes Research, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Keith D. Eaton
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Renato G. Martins
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Scott D. Ramsey
- Hutchinson Institute for Cancer Outcomes Research, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA
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Moore CJ, Shalowitz DI. State Standards for Insurance Access to Oncologists. JNCI Cancer Spectr 2021; 5:pkaa113. [PMID: 33554036 PMCID: PMC7853180 DOI: 10.1093/jncics/pkaa113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/28/2020] [Accepted: 11/20/2020] [Indexed: 11/13/2022] Open
Abstract
As the market for health insurance plans expands, each state is responsible for setting standards to ensure that plans contain adequate coverage for cancer care. Little is currently known about what criteria states use for network adequacy of insurance plans. We contacted representatives of the Department of Insurance (or equivalent) for 50 states and the District of Columbia, as well as searched official state websites to compile data on network adequacy standards for cancer care nationwide. The standards of 16 (31.4%) states contained only qualitative elements for access to an oncologist (eg, "reasonable access"), 7 (13.7%) states included only quantitative elements (eg, travel distance and time restrictions), and 24 (47.1%) states included standards with both qualitative and quantitative elements. Standards from 4 states were not available. States should make certain that robust, transparent protections exist to ensure that patients are able to access high-quality cancer care without experiencing the financial toxicity associated with out-of-network billing.
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Affiliation(s)
- Catherine J Moore
- Department of Obstetrics and Gynecology, George Washington University, Washington, DC, USA
| | - David I Shalowitz
- Department of Obstetrics and Gynecology, George Washington University, Washington, DC, USA.,Section on Gynecologic Oncology, Department of Obstetrics and Gynecology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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17
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Trends in the Geospatial Distribution of Adult Inpatient Surgical Cancer Care Across the United States. J Gastrointest Surg 2020; 24:2127-2134. [PMID: 31396841 DOI: 10.1007/s11605-019-04343-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/24/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The relationship and trends of geography and travel distance to access surgical cancer care has been poorly characterized. The objective of the study was to define the geographic distribution of access to hospital-based operative cancer care across the USA. METHODS A cohort analysis was performed using the 2005 and 2015 American Hospital Association Annual Survey, Census Bureau Data for 2010, and the American Community Survey 5-year estimates for 2011 to 2016. RESULTS The number of hospitals that provided surgical services with an approved American College of Surgeons (ACS) cancer program slightly increased over the time periods examined (2005, n = 1203 vs. 2015, n = 1284; p = 0.7210). Based on geospatial analysis, 18,214,994 (5.9%) people lived more than 60 min from a hospital with a cancer program in 2005 compared with 34,630,516 (11.2%) by 2015. Communities within a 60-min drive time were more likely to be composed of individuals who completed high school (85.9% vs. 84.2%), were employed (62.7% vs. 57.1%), had a higher median household income ($67.4 k vs. $53.2 k), and lived within states that had expanded Medicaid (62.5% vs. 48.9%) (all p < 0.0001). In contrast, communities outside of a 60-min drive time had a greater proportion of individuals below the federal poverty level (18.3% vs. 16.5%; p < 0.0001). CONCLUSIONS While the number of hospitals with ACS approved cancer program designation increased over the last decade, the number of people living greater than 60 min from an approved cancer programs nearly doubled. These data highlight worrisome geospatial trends that may make access to cancer care for certain patient populations increasingly challenging.
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Abstract
OBJECTIVE To estimate how implementation of the 2010 Affordable Care Act (ACA) might be associated with stage at diagnosis and time to treatment for women with ovarian cancer. METHODS We conducted a retrospective cohort study using difference-in-differences analysis comparing stage at diagnosis and time to treatment before and after implementation of the ACA among women with ovarian cancer aged 21-64 years (exposure group) compared with women aged 65 years or older (control group). Using 2004-2015 data from the National Cancer Database, outcomes were analyzed overall and by insurance type and race, adjusting for urban-rural, income and education level, comorbidities, distance traveled for care, region, and care at an academic center. RESULTS A total of 39,999 ovarian cancer cases prereform and 36,564 postreform were identified for women aged 21-64 years compared with 31,290 cases prereform and 29,807 postreform for women aged 65 years or older. The ACA was associated with increased early-stage diagnosis detection for women aged 21-64 years compared with women 65 and older (difference-in-differences 1.4%, 95% CI 0.4-2.4). The ACA was associated with more women receiving treatment within 30 days of ovarian cancer diagnosis (2.3%, 95% CI 1.7-3.0). Among women with public insurance, the ACA was associated with a significant improvement in early-stage diagnosis and receipt of treatment within 30 days of diagnosis (difference-in-differences 2.7%, 95% CI 1.0-4.5, difference-in-differences 2.5%, 95% CI 1.2-3.8). Improvements in time to treatment were seen across race and income groups. CONCLUSION Implementation of the ACA was associated with earlier ovarian cancer stage at detection and treatment within 30 days of diagnosis.
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Sheng JY, Visvanathan K, Thorner E, Wolff AC. Breast cancer survivorship care beyond local and systemic therapy. Breast 2020; 48 Suppl 1:S103-S109. [PMID: 31839149 DOI: 10.1016/s0960-9776(19)31135-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Despite persistent inequities in access to care and treatments, advances in combined modality care have led to a steady improvement in outcomes for breast cancer patients across the globe. When estimating the magnitude of clinical benefit of therapies, providers and patients must contend with a multitude of factors that impact treatment decisions and can have long-term effects on quality of life and survival. These include commonly described early toxicities, like aromatase inhibitor-associated musculoskeletal syndrome and neuropathy. But longer-term comorbidities often observed among cancer survivors including weight gain, obesity, infertility, psychological distress, sexual dysfunction, second cancers, bone loss, and body image issues can have lasting effects on quality of life. Equally important, system-level factors such as access to care and resource allocation can have a systemic impact on survival and on the quality of survivorship. Financial toxicity including underemployment can have a lasting impact on patients and caregivers. The resulting disparities in access to treatment can help explain much of the observed variability in outcomes, even within high-income countries like the US. This article revisits some of secondary effects from therapies discussed in a prior 2015 review article, along with other impediments to the optimal delivery of breast cancer care that can affect patients anywhere.
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Affiliation(s)
- Jennifer Y Sheng
- The Johns Hopkins University School of Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Kala Visvanathan
- The Johns Hopkins University School of Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Elissa Thorner
- The Johns Hopkins University School of Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Antonio C Wolff
- The Johns Hopkins University School of Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA.
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20
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Schlick CJ, Yang AD. Is there value in cancer center accreditation? Am J Surg 2020; 220:27-28. [PMID: 32416939 DOI: 10.1016/j.amjsurg.2020.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/01/2020] [Accepted: 05/02/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Cary Jo Schlick
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Anthony D Yang
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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21
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Politi MC, Grant RL, George NP, Barker AR, James AS, Kuroki LM, McBride TD, Liu J, Goodwin CM. Improving Cancer Patients' Insurance Choices (I Can PIC): A Randomized Trial of a Personalized Health Insurance Decision Aid. Oncologist 2020; 25:609-619. [PMID: 32108976 DOI: 10.1634/theoncologist.2019-0703] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 01/17/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Many cancer survivors struggle to choose a health insurance plan that meets their needs because of high costs, limited health insurance literacy, and lack of decision support. We developed a web-based decision aid, Improving Cancer Patients' Insurance Choices (I Can PIC), and evaluated it in a randomized trial. MATERIALS AND METHODS Eligible individuals (18-64 years, diagnosed with cancer for ≤5 years, English-speaking, not Medicaid or Medicare eligible) were randomized to I Can PIC or an attention control health insurance worksheet. Primary outcomes included health insurance knowledge, decisional conflict, and decision self-efficacy after completing I Can PIC or the control. Secondary outcomes included knowledge, decisional conflict, decision self-efficacy, health insurance literacy, financial toxicity, and delayed care at a 3-6-month follow-up. RESULTS A total of 263 of 335 eligible participants (79%) consented and were randomized; 206 (73%) completed the initial survey (106 in I Can PIC; 100 in the control), and 180 (87%) completed a 3-6 month follow-up. After viewing I Can PIC or the control, health insurance knowledge and a health insurance literacy item assessing confidence understanding health insurance were higher in the I Can PIC group. At follow-up, the I Can PIC group retained higher knowledge than the control; confidence understanding health insurance was not reassessed. There were no significant differences between groups in other outcomes. Results did not change when controlling for health literacy and employment. Both groups reported having limited health insurance options. CONCLUSION I Can PIC can improve cancer survivors' health insurance knowledge and confidence using health insurance. System-level interventions are needed to lower financial toxicity and help patients manage care costs. IMPLICATIONS FOR PRACTICE Inadequate health insurance compromises cancer treatment and impacts overall and cancer-specific mortality. Uninsured or underinsured survivors report fewer recommended cancer screenings and may delay or avoid needed follow-up cancer care because of costs. Even those with adequate insurance report difficulty managing care costs. Health insurance decision support and resources to help manage care costs are thus paramount to cancer survivors' health and care management. We developed a web-based decision aid, Improving Cancer Patients' Insurance Choices (I Can PIC), and evaluated it in a randomized trial. I Can PIC provides health insurance information, supports patients through managing care costs, offers a list of financial and emotional support resources, and provides a personalized cost estimate of annual health care expenses across plan types.
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Affiliation(s)
- Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Rachel L Grant
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Nerissa P George
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Abigail R Barker
- Brown School and Center for Health Economics and Policy, Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Aimee S James
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Lindsay M Kuroki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Timothy D McBride
- Brown School and Center for Health Economics and Policy, Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Jingxia Liu
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Courtney M Goodwin
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
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Fullmer T, Wilde DC, Shi JW, Wagner T, Skinner H, Eicher SA, Sandulache VC, Hernandez DJ. Demographic and Tumor Characteristic Impact on Laryngeal Cancer Outcomes in a Minority Underserved Patient Population. Otolaryngol Head Neck Surg 2020; 162:888-896. [PMID: 32093532 DOI: 10.1177/0194599820907064] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Advanced laryngeal squamous cell carcinoma remains associated with approximately 50% mortality at 5 years. Delivery of multimodality treatment remains critical to maximizing survival for this disease, but achieving this at a national level remains a difficult undertaking, particularly in under- and uninsured patients as well as minority patients. We sought to evaluate laryngeal cancer treatment delivery and clinical outcomes in a predominantly minority and underserved cohort of largely under- and uninsured patients in a county hospital. STUDY DESIGN Retrospective cohort study. SETTING Tertiary care county hospital in Houston, Texas. SUBJECTS AND METHODS Patients (N = 210) with a new diagnosis of laryngeal squamous cell carcinoma treated between 2005 and 2015 were included in a retrospective analysis of patient demographics, tumor and treatment characteristics, and oncologic outcomes. RESULTS The majority of patients presented with advanced disease (T4 = 43%, N>0 = 45%). Treatment selection was compliant with National Comprehensive Cancer Network guidelines in 81% of cases, but 76% of patients who required adjuvant radiotherapy were unable to start it within 6 weeks postsurgery. Overall survival and disease-free survival were 52% and 63% for the entire cohort, respectively. Supraglottic subsite and nodal metastases were significantly associated with decreased overall survival and disease-free survival. Race/ethnicity and insurance status were not associated with worse oncologic outcomes. CONCLUSION Under- and uninsured patients often present with advanced laryngeal cancer. Oncologic outcomes in this cohort of patients is similar to that of other published series. Moreover, tumor characteristics rather than demographic variables drive oncologic outcomes for the predominantly minority and underserved patients seeking care in our tertiary care county hospital.
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Affiliation(s)
- Tanner Fullmer
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - David C Wilde
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Justin W Shi
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Timothy Wagner
- Department of Radiation Oncology, UT Health San Antonio, San Antonio, Texas, USA
| | - Heath Skinner
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - Susan A Eicher
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Vlad C Sandulache
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - David J Hernandez
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
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Shaver AL, Cao Y, Noyes K. General Health Care Utilization Among Nonelderly Cancer Survivors Before and After Affordable Care Act Implementation: Early Results. JCO Oncol Pract 2020; 16:e581-e589. [PMID: 32069189 DOI: 10.1200/jop.19.00498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The number of nonelderly cancer survivors is expected to grow and so are their health care costs. Many cancer survivors worry about medical bills. This study examined the impact of the Affordable Care Act (ACA) on the rate of insurance, average annual health care expenditure, and patient care experience among cancer survivors and investigated the patient characteristics that were associated with highly rated care experiences before and after ACA implementation. METHODS The study is a cross-sectional analysis of adult, nonelderly cancer survivors in the 2011 and 2016 Medical Expenditure Panel Survey who completed health care experience questionnaires. Percent covered by insurance both before and after the ACA was calculated, including total out-of-pocket (OOP) expenses as a percentage of overall health care expenditure per patient. Regression was performed to determine characteristics associated with patient experience ratings. RESULTS Health insurance coverage for cancer survivors was higher in 2016 than in 2011 (98.4% v 94.4%; P = .006). OOP spending as a percentage of health care expenditure among those with expenses decreased and was most striking in those with no insurance. Privately insured individuals were 3 times as likely to rate their care experience high compared with those with no insurance (odds ratio, 3.31; P < .0001). Those with above-average ratings of self-health and with few comorbidities rated their care experiences highly. CONCLUSION After the ACA, OOP costs have decreased for all types of insurance coverage. The association between patient experience and health status warrants additional study to better manage and coordinate the care of such patients.
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Affiliation(s)
- Amy L Shaver
- Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY
| | - Ying Cao
- Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY
| | - Katia Noyes
- Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY
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24
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Kehl KL, Keating NL, Giordano SH, Schrag D. Insurance Networks and Access to Affordable Cancer Care. J Clin Oncol 2020; 38:310-315. [PMID: 31804867 DOI: 10.1200/jco.19.01484] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
| | - Nancy L Keating
- Harvard Medical School and Brigham and Women's Hospital, Boston, MA
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Abstract
Financial barriers to clinical trial enrollment are an area of active investigation. Financial toxicity as a concept describes how high costs and financial burden can lead to compromised care and outcomes. Despite the potential to yield large survival benefits and improved access to cutting-edge therapies, less than 5% of adult patients with cancer are enrolled in a clinical trial. Disparities in trial enrollment exist along age, ethnic, and sociodemographic lines, with younger, poorer, nonwhite patients with private insurance-the exact population who may be at highest risk for financial toxicity-less likely to participate. Cost and insurance concerns remain an obstacle for clinical trial enrollment for certain patient populations. Changing the clinical trial paradigm with a focus on addressing structural and clinical barriers to clinical trial enrollment is paramount. This includes expanding access to clinical trials within community populations, advocating for health policy changes to guarantee insurance coverage of clinical trial standard-of-care health care, and considering noncoercive financial assistance (particularly for indirect costs like travel and lodging) for participants to defray their additional costs of participation. Additional steps toward education, cost transparency, and expansion of foundation assistance may also improve equitable access to clinical trials for all.
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Affiliation(s)
- Fumiko Chino
- 1 Duke University Radiation Oncology, Durham, NC
| | - S Yousuf Zafar
- 2 Sanford School of Public Policy, Duke Cancer Institute, Durham, NC
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Temkin SM, Rimel BJ, Bruegl AS, Gunderson CC, Beavis AL, Doll KM. A contemporary framework of health equity applied to gynecologic cancer care: A Society of Gynecologic Oncology evidenced-based review. Gynecol Oncol 2018; 149:70-77. [PMID: 29605053 DOI: 10.1016/j.ygyno.2017.11.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/19/2017] [Accepted: 11/07/2017] [Indexed: 01/21/2023]
Abstract
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.
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Affiliation(s)
- Sarah M Temkin
- Virginia Commonwealth University, Massey Cancer Center, Richmond, VA, USA
| | - B J Rimel
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Camille C Gunderson
- Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma city, OK, USA
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Somayaji D, Chang YP, Casucci S, Xue Y, Hewner S. Exploring Medicaid claims data to understand predictors of healthcare utilization and mortality for Medicaid individuals with or without a diagnosis of lung cancer: a feasibility study. Transl Behav Med 2018; 8:400-408. [DOI: 10.1093/tbm/iby023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
| | - Yu-Ping Chang
- University at Buffalo School of Nursing, Buffalo, NY, USA
| | - Sabrina Casucci
- Department of Industrial and Systems Engineering, University at Buffalo, Buffalo, NY, USA
| | - Yuqing Xue
- University at Buffalo School of Nursing, Buffalo, NY, USA
| | - Sharon Hewner
- University at Buffalo School of Nursing, Buffalo, NY, USA
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Duska LR. Access to quality gynecologic oncology care: A work in progress. Cancer 2018; 124:2680-2683. [DOI: 10.1002/cncr.31391] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 03/19/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Linda R. Duska
- Division of Gynecologic Oncology; University of Virginia School of Medicine; Charlottesville Virginia
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Shalowitz DI, Huh WK. Access to gynecologic oncology care and the network adequacy standard. Cancer 2018; 124:2677-2679. [DOI: 10.1002/cncr.31392] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 01/28/2018] [Accepted: 01/30/2018] [Indexed: 11/05/2022]
Affiliation(s)
- David I. Shalowitz
- Section on Gynecologic Oncology, Department of Obstetrics and Gynecology; Wake Forest University; Winston-Salem North Carolina
- Department of Implementation Science; Wake Forest University; Winston-Salem North Carolina
| | - Warner K. Huh
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology; University of Alabama at Birmingham School of Medicine; Birmingham Alabama
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Abstract
The Affordable Care Act (ACA) has reformed US health care delivery through insurance coverage expansion, experiments in payment design, and funding for patient-centered clinical and health care delivery research. The impact on cancer care specifically has been far reaching, with new ACA-related programs that encourage coordinated, patient-centered, cost-effective care. Insurance expansions through private exchanges and Medicaid, along with preexisting condition clauses, have helped more than 20 million Americans gain health care coverage. Accountable care organizations, oncology patient-centered medical homes, and the Oncology Care Model-all implemented through the Center for Medicare & Medicaid Innovation-have initiated an accelerating shift toward value-based cancer care. Concurrently, evidence for better cancer outcomes and improved quality of cancer care is starting to accrue in the wake of ACA implementation.
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Affiliation(s)
- Gabriel A Brooks
- From the *Dartmouth-Hitchcock Medical Center, Lebanon, NH; †The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH; ‡Texas Oncology, Dallas, TX; and §The US Oncology Network, The Woodlands, TX
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Alvarez EM, Keegan TH, Johnston EE, Haile R, Sanders L, Wise PH, Saynina O, Chamberlain LJ. The Patient Protection and Affordable Care Act dependent coverage expansion: Disparities in impact among young adult oncology patients. Cancer 2017; 124:110-117. [DOI: 10.1002/cncr.30978] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 07/10/2017] [Accepted: 08/02/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Elysia M. Alvarez
- Division of Pediatric Hematology and Oncology; Stanford University School of Medicine; Palo Alto California
| | - Theresa H. Keegan
- Division of Hematology and Oncology; University of California at Davis School of Medicine; Sacramento California
| | - Emily E. Johnston
- Division of Pediatric Hematology and Oncology; Stanford University School of Medicine; Palo Alto California
| | - Robert Haile
- Division of Oncology; Stanford University School of Medicine; Palo Alto California
| | - Lee Sanders
- Division of General Pediatrics; Stanford University School of Medicine; Palo Alto California
| | - Paul H. Wise
- The Center for Policy, Outcomes and Prevention, Stanford University; Palo Alto California
| | - Olga Saynina
- The Center for Policy, Outcomes and Prevention, Stanford University; Palo Alto California
| | - Lisa J. Chamberlain
- Division of General Pediatrics; Stanford University School of Medicine; Palo Alto California
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Johnston EE, Alvarez E, Saynina O, Sanders L, Bhatia S, Chamberlain LJ. End-of-Life Intensity for Adolescents and Young Adults With Cancer: A Californian Population-Based Study That Shows Disparities. J Oncol Pract 2017; 13:e770-e781. [PMID: 28829692 DOI: 10.1200/jop.2016.020586] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Cancer is the leading cause of nonaccidental death among adolescents and young adults (AYAs). High-intensity end-of-life care is expensive and may not be consistent with patient goals. However, the intensity of end-of-life care for AYA decedents with cancer-especially the effect of care received at specialty versus nonspecialty centers-remains understudied. METHODS We conducted a retrospective, population-based analysis with the California administrative discharge database that is linked to death certificates. The cohort included Californians age 15 to 39 years who died between 2000 and 2011 with cancer. Intense end-of-life interventions included readmission, admission to an intensive care unit, intubation in the last month of life, and in-hospital death. Specialty centers were defined as Children's Oncology Group centers and National Cancer Institute-designated comprehensive cancer centers. RESULTS Of the 12,938 AYA cancer decedents, 59% received at least one intense end-of-life care intervention, and 30% received two or more. Patients treated at nonspecialty centers were more likely than those at specialty-care centers to receive two or more intense interventions (odds ratio [OR], 1.46; 95% CI, 1.32 to 1.62). Sociodemographic and clinical factors associated with two or more intense interventions included minority race/ethnicity (Black [OR, 1.35, 95% CI, 1.17 to 1.56]; Hispanic [OR, 1.24; 95% CI, 1.12 to 1.36]; non-Hispanic white: reference), younger age (15 to 21 years [OR, 1.36; 95% CI, 1.19 to 1.56; 22 to 29 years [OR,1.26; 95% CI,1.14 to 1.39]; ≥ 30 years: reference), and hematologic malignancies (OR, 1.53; 95% CI, 1.41 to 1.66; solid tumors: reference). CONCLUSION Thirty percent of AYA cancer decedents received two or more high-intensity end-of-life interventions. In addition to sociodemographic and clinical characteristics, hospitalization in a nonspecialty center was associated with high-intensity end-of-life care. Additional research is needed to determine if these disparities are consistent with patient preference.
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Affiliation(s)
- Emily E Johnston
- Stanford University School of Medicine, Palo Alto, CA; and University of Alabama School of Medicine at Birmingham, Birmingham, AL
| | - Elysia Alvarez
- Stanford University School of Medicine, Palo Alto, CA; and University of Alabama School of Medicine at Birmingham, Birmingham, AL
| | - Olga Saynina
- Stanford University School of Medicine, Palo Alto, CA; and University of Alabama School of Medicine at Birmingham, Birmingham, AL
| | - Lee Sanders
- Stanford University School of Medicine, Palo Alto, CA; and University of Alabama School of Medicine at Birmingham, Birmingham, AL
| | - Smita Bhatia
- Stanford University School of Medicine, Palo Alto, CA; and University of Alabama School of Medicine at Birmingham, Birmingham, AL
| | - Lisa J Chamberlain
- Stanford University School of Medicine, Palo Alto, CA; and University of Alabama School of Medicine at Birmingham, Birmingham, AL
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Kehl KL, Fullmer CP, Fu S, George GC, Hess KR, Janku F, Karp DD, Kato S, Kizer CK, Kurzrock R, Naing A, Pant S, Piha-Paul SA, Subbiah V, Tsimberidou AM, Hong DS. Insurance Clearance for Early-Phase Oncology Clinical Trials Following the Affordable Care Act. Clin Cancer Res 2017; 23:4155-4162. [PMID: 28729355 DOI: 10.1158/1078-0432.ccr-16-3027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 02/02/2017] [Accepted: 05/03/2017] [Indexed: 11/16/2022]
Abstract
Purpose: The Affordable Care Act (ACA) required that private insurance plans allow clinical trial participation and cover standard-of-care costs, but the impact of this provision has not been well-characterized. We assessed rates of insurance clearance for trial participation within our large early-phase clinical trials program, before and after implementation of the requirement.Experimental Design: We analyzed the departmental database for the Clinical Center for Targeted Therapy (CCTT) at MD Anderson Cancer Center (Houston, TX). Among patients referred for sponsored trials, we described rates of insurance clearance and prolonged time to clearance (at least 14 days) from July 2012 to June 2013 (baseline), July 2013-December 2013 (following CCTT staffing changes in July 2103), and January 2014-June 2015 (following implementation of the ACA). We used multivariable logistic regression models to compare rates across these time periods.Results: We identified 2,404 referrals for insurance clearance. Among privately insured patients, insurance clearance rates were higher for those referred from January 2014 to June 2015 than for those referred from July 2012 to June 2013 (OR, 4.72; 95% CI, 2.96-7.51). There was no association between referral period and clearance rates for Medicare/Medicaid patients (P = 0.25). Referral from January 2014 to June 2015 was associated with lower rates of prolonged clearance among both privately insured (OR 0.57; 95% CI, 0.38-0.86) and Medicare/Medicaid patients (OR 0.39; 95% CI, 0.19-0.83).Conclusions: Within our large early-phase clinical trials program, insurance clearance rates among privately insured patients improved following implementation of the ACA's requirement for coverage of standard-of-care costs. Clin Cancer Res; 23(15); 4155-62. ©2017 AACR.
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Affiliation(s)
- Kenneth L Kehl
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Cheryl P Fullmer
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Siqing Fu
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Goldy C George
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kenneth R Hess
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Filip Janku
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel D Karp
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shumei Kato
- The Center for Personalized Cancer Therapy and Clinical Trials, University of California, San Diego, California
| | - Cynthia K Kizer
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Razelle Kurzrock
- The Center for Personalized Cancer Therapy and Clinical Trials, University of California, San Diego, California
| | - Aung Naing
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shubham Pant
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sarina A Piha-Paul
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Vivek Subbiah
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Apostolia M Tsimberidou
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David S Hong
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Reeder-Hayes KE, Anderson BO. Breast Cancer Disparities at Home and Abroad: A Review of the Challenges and Opportunities for System-Level Change. Clin Cancer Res 2017; 23:2655-2664. [PMID: 28572260 PMCID: PMC5499686 DOI: 10.1158/1078-0432.ccr-16-2630] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 03/03/2017] [Accepted: 04/06/2017] [Indexed: 01/06/2023]
Abstract
Sizeable disparities exist in breast cancer outcomes, both between Black and White patients in the United States, and between patients in the United States and other high-income countries compared with low- and middle-income countries (LMIC). In both settings, health system factors are key drivers of disparities. In the United States, Black women are more likely to die of breast cancer than Whites and have poorer outcomes, even among patients with similar stage and tumor subtype. Over-representation of higher risk "triple-negative" breast cancers contributes to breast cancer mortality in Black women; however, the greatest survival disparities occur within the good-prognosis hormone receptor-positive (HR+) subtypes. Disparities in access to treatment within the complex U.S. health system may be responsible for a substantial portion of these differences in survival. In LMICs, breast cancer mortality rates are substantially higher than in the United States, whereas incidence continues to rise. This mortality burden is largely attributable to health system factors, including late-stage presentation at diagnosis and lack of availability of systemic therapy. This article will review the existing evidence for how health system factors in the United States contribute to breast cancer disparities, discuss methods for studying the relationship of health system factors to racial disparities, and provide examples of health system interventions that show promise for mitigating breast cancer disparities. We will then review evidence of global breast cancer disparities in LMICs, the treatment factors that contribute to these disparities, and actions being taken to combat breast cancer disparities around the world. Clin Cancer Res; 23(11); 2655-64. ©2017 AACRSee all articles in this CCR Focus section, "Breast Cancer Research: From Base Pairs to Populations."
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Affiliation(s)
- Katherine E Reeder-Hayes
- Division of Hematology and Oncology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
- The University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Benjamin O Anderson
- Departments of Surgery and Global Health Medicine, School of Medicine, University of Washington, Seattle, Washington
- Program in Epidemiology, Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
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