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Li L, Yang C, Huang Y, Zhan S, Hu L, Zou J, Yu M, Mazumdar M, Liu B. Medicaid expansion in California and breast cancer incidence across neighborhoods with varying social vulnerabilities. Cancer Causes Control 2024:10.1007/s10552-024-01893-1. [PMID: 38874815 DOI: 10.1007/s10552-024-01893-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 05/31/2024] [Indexed: 06/15/2024]
Abstract
PURPOSE To investigate changes in breast cancer incidence rates associated with Medicaid expansion in California. METHODS We extracted yearly census tract-level population counts and cases of breast cancer diagnosed among women aged between 20 and 64 years in California during years 2010-2017. Census tracts were classified into low, medium and high groups according to their social vulnerability index (SVI). Using a difference-in-difference (DID) approach with Poisson regression models, we estimated the incidence rate, incidence rate ratio (IRR) during the pre- (2010-2013) and post-expansion periods (2014-2017), and the relative IRR (DID estimates) across three groups of neighborhoods. RESULTS Prior to the Medicaid expansion, the overall incidence rate was 93.61, 122.03, and 151.12 cases per 100,000 persons among tracts with high, medium, and low-SVI, respectively; and was 96.49, 122.07, and 151.66 cases per 100,000 persons during the post-expansion period, respectively. The IRR between high and low vulnerability neighborhoods was 0.62 and 0.64 in the pre- and post-expansion period, respectively, and the relative IRR was 1.03 (95% CI 1.00 to 1.06, p = 0.026). In addition, significant DID estimate was only found for localized breast cancer (relative IRR = 1.05; 95% CI, 1.01 to 1.09, p = 0.049) between high and low-SVI neighborhoods, not for regional and distant cancer stage. CONCLUSIONS The Medicaid expansion had differential impact on breast cancer incidence across neighborhoods in California, with the most pronounced increase found for localized cancer stage in high-SVI neighborhoods. Significant pre-post change was only found for localized breast cancer between high and low-SVI neighborhoods.
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Affiliation(s)
- Lihua Li
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, USA
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, USA
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Chen Yang
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, USA
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, USA
| | - Yuanhui Huang
- Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Serena Zhan
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, USA
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Liangyuan Hu
- Department of Biostatistics & Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Joe Zou
- Information Management Services, Inc, Rockville, MD, USA
| | - Mandi Yu
- Surveillance Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Madhu Mazumdar
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, USA
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, USA
| | - Bian Liu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, USA.
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, USA.
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Megwalu UC, Ma Y, Divi V, Tian L. Insurance Disparities in Quality of Care Among Patients With Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg 2024:2819463. [PMID: 38869878 DOI: 10.1001/jamaoto.2024.1338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
Importance Significant insurance status disparities have been demonstrated in head and neck cancer (HNC) outcomes. The effects of insurance status on HNC outcomes may be explained by differential access to high-quality care. Objective To evaluate the association of insurance status with the quality of the treating hospital and receipt of guideline-compliant care among patients with HNC. Design, Setting, and Participants This retrospective cohort study of data from the California Cancer Registry dataset linked with discharge records and hospital characteristics from the California Department of Health Care Access and Information included adult patients with HNC diagnosed between January 1, 2010, and December 31, 2019. Data were analyzed from May 10, 2023, to March 25, 2024. Exposures Insurance status: commercial, Medicare, Medicaid, uninsured, other, or unknown. Main Outcomes and Measures Quality of the treating hospital (tertiles), receipt of National Comprehensive Cancer Network guideline-compliant care, and overall survival. Results A total of 23 933 patients (mean [SD] age, 64.8 [12.3] years; 75.3% male) met the inclusion criteria. Treatment in top-tertile hospitals (hazard ratio, 0.87; 95% CI, 0.79-0.95) was associated with improved overall survival compared with treatment in bottom-tertile hospitals. Medicare (odds ratio [OR], 0.78; 95% CI, 0.73-0.84), Medicaid (OR, 0.60; 95% CI, 0.54-0.66), and uninsured (OR, 0.38; 95% CI, 0.29-0.49) status were associated with lower likelihood of treatment in high-quality hospitals compared with commercial insurance. Among patients with advanced disease, Medicaid (OR, 0.72; 95% CI, 0.62-0.83) and uninsured (OR, 0.64; 95% CI, 0.44-0.93) patients were less likely to receive dual-modality therapy. Among patients with surgically resected advanced disease, Medicaid coverage (OR, 0.73; 95% CI, 0.58-0.93) was associated with lower likelihood of receiving adjuvant radiotherapy. Conclusions and Relevance This study found significant insurance disparities in quality of care among patients with HNC. These findings highlight the need for continued health insurance reform in the US to improve the quality of insurance coverage, in addition to expanding access to health insurance.
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Affiliation(s)
- Uchechukwu C Megwalu
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Yifei Ma
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Vasu Divi
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Lu Tian
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, California
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Nurimba M, Sheth M, Swanson M, Chambers T. The Impact of Race and the Affordable Care Act on Thyroid Carcinoma Outcomes: A National Cancer Database Study. Laryngoscope 2024. [PMID: 38841865 DOI: 10.1002/lary.31559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 04/16/2024] [Accepted: 05/23/2024] [Indexed: 06/07/2024]
Abstract
OBJECTIVE To assess the impact of race and the Affordable Care Act (ACA) of 2010 on disease presentation and overall survival for patients with well-differentiated thyroid carcinoma. STUDY DESIGN Cross-sectional study of patients (n = 51,078) who underwent partial or total thyroidectomy with or without postoperative radioactive iodine (RAI) for well-differentiated thyroid carcinoma between 2004 and 2018 in the National Cancer Database (NCDB). METHODS Cumulative survival (CS) was assessed with Cox proportional hazard regression analyses. RESULTS There were significant disparities in disease presentation at the time of diagnosis, with Black, Asian/Pacific Islander (API), and Hispanic patients were more likely to have metastatic disease (p < 0.001) and higher TNM stage (p < 0.001) at the time of diagnosis compared to White patients. Black patients had significantly increased risk of death (HR 1.147, 95%CI 1.021-1.289) but API patients had improved CS (HR 0.730, 95% CI 0.608-0.877) compared to White patients. Passage of the ACA was associated with lower risk of mortality, regardless of whether patients lived in states that did not expand Medicaid (HR 0.866, 95% CI 0.823-0.910) or whether they lived in expansion states (HR 0.818, 95% CI 0.758-0.884). CONCLUSION Racial disparities significantly impact thyroid carcinoma diagnosis and treatment in the United States but have improved over time. Both expansion and non-expansion states had improved survival outcomes over time, and suggesting analysis of the ACA's long-term impact and ability to address health inequities is still warranted. LEVEL OF EVIDENCE Level 3 Laryngoscope, 2024.
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Affiliation(s)
- Margaret Nurimba
- Tina and Rick Caruso Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - Megha Sheth
- Keck School of Medicine of the University of Southern California, Los Angeles, California, U.S.A
| | - Mark Swanson
- Tina and Rick Caruso Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - Tamara Chambers
- Tina and Rick Caruso Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, California, U.S.A
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Olateju OA, Shen C, Thornton JD. The Affordable Care Act and income-based disparities in health care coverage and spending among nonelderly adults with cancer. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae050. [PMID: 38812986 PMCID: PMC11135644 DOI: 10.1093/haschl/qxae050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/12/2024] [Accepted: 04/23/2024] [Indexed: 05/31/2024]
Abstract
The Patient Protection and Affordable Care Act (ACA) significantly reduced uninsured individuals and improved financial protection; however, escalating costs of cancer treatment has led to substantial out-of-pocket expenses, causing severe financial and mental health distress for individuals with cancer. Mixed evidence on the ACA's ongoing impact highlights the necessity of assessing health-spending changes across income groups for informed policy interventions. In our nationally representative survey evaluating the early- and long-term effects of the ACA on nonelderly adult patients with cancer, we categorized individuals-based income subgroups defined by the ACA for eligibility. We found that ACA implementation increased insurance coverage, which was particularly evident after 2 years of implementation. Early post-ACA (within two years of implementation), there were declines in out-of-pocket spending for the lowest and low-income groups by 26.52% and 38.31%, respectively, persisting long-term only for the lowest-income group. High-income groups experienced continuously increased out-of-pocket and premium spending by 25.39% and 34.28%, respectively, with a notable 122% increase in the risk of high-burden spending. This study provides robust evidence of income-based disparities in financial burden for cancer care, emphasizing the need for health care policies promoting equitable care and addressing spending disparities across income brackets.
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Affiliation(s)
- Olajumoke A Olateju
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, TX 77204-5000, United States
| | - Chan Shen
- Departments of Surgery and Public Health Sciences, Penn State Cancer Institute, Hershey, PA 17033, United States
| | - James Douglas Thornton
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, TX 77204-5000, United States
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Arch RS, Fei-Zhang DJ, Patel U, Rastatter JC. Influence of Medicaid Expansion on Head and Neck Squamous Cell Carcinoma Presentation and Survival. Otolaryngol Head Neck Surg 2024; 170:431-437. [PMID: 37811691 DOI: 10.1002/ohn.552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 08/24/2023] [Accepted: 09/02/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVE To compare head and neck squamous cell carcinoma stage at presentation and survival in Medicaid-expanded states versus nonexpanded states. STUDY DESIGN Retrospective cohort. SETTING Northwestern University Feinberg School of Medicine. METHODS The Head and Neck with human papillomavirus Status Database within the Surveillance, Epidemiology, and End Results (SEER) Program was queried for cases of head and neck squamous cell carcinoma (HNSCC) diagnosed in the years 2010 to 2016. Cases were grouped according to their respective state Medicaid expansion status. Multivariable logistic regressions and multivariable Cox proportional hazards models were used to evaluate associations with stage IV disease and survival. RESULTS Compared to nonexpanded states, Medicaid-expanded states had a significantly larger proportion of Medicaid patients (20.3% vs 16.7%, P = .0009) and a significantly smaller proportion of uninsured patients (1.7% vs 10.1%, P < .0001). The case selection process resulted in 2215 patients meeting inclusion criteria. In multivariable analysis, cases under Medicaid expansion were 31% less likely to present with stage IV disease compared to cases in nonexpanded states (odds ratio: 0.69, 95% confidence interval [CI]: 0.51-0.93). In the multivariable Cox proportional hazards model, cases under Medicaid expansion had significantly better mortality outcomes and were 32% less likely to die compared to cases in nonexpanded states (hazard ratio: 0.68, 95% CI: 0.55-0.84). CONCLUSION Medicaid expansion is associated with fewer stage IV cases and improved survival of HNSCC cases. These findings support continued efforts to expand Medicaid coverage.
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Affiliation(s)
- Rebecca Sinard Arch
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - David J Fei-Zhang
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Urjeet Patel
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jeffrey C Rastatter
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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Ezeh UC, Al-Awady A, Buitron I, Lee M, Forman G, Peifer S, Deo A, Sweeny L, Weed D, Kobetz EK, Reis IM, Franzmann E. Investigating Disparities in Hypopharyngeal/Laryngeal Cancer Survival in Florida With Geospatial Mapping Analysis. Cancer Control 2024; 31:10732748241246958. [PMID: 38623948 PMCID: PMC11022680 DOI: 10.1177/10732748241246958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 03/01/2024] [Accepted: 03/21/2024] [Indexed: 04/17/2024] Open
Abstract
OBJECTIVE Identify predictors of overall survival (OS) after hypopharyngeal/laryngeal cancer in Florida. MATERIAL AND METHODS We conducted a retrospective cohort study using data from the Florida Cancer Data System (FCDS) on patients diagnosed with hypopharyngeal or laryngeal cancer from 2010-2017. Primary outcome was OS. Hazard ratios (HRs) were estimated from univariable and multivariable Cox regression models for OS. Data was analyzed from November 1, 2022, to June 30, 2023. RESULTS We analyzed 6771 patients, who were primarily male (81.2%), White non-Hispanic (WNH) (78.2%), publicly insured (70.1%), married (51.8%), and residents of urban counties (73.6%). Black patients were more likely to be younger at diagnosis (38.9%), single (43.4%), to have distant SEER stage disease (25.6%). Median OS were lowest among patients who were uninsured (34 months), with hypopharyngeal site disease (18 months), and a smoking history (current: 34 months, former: 46 months, no smoking: 63 months). Multivariable Cox regression analysis showed worse OS for single/unmarried vs married (HR 1.47 [95%CI: 1.36-1.59], P < .001), history of tobacco use (current: HR 1.62 [95%CI: 1.440-1.817], P < .001; former smokers: (HR 1.28 [95%CI: 1.139-1.437], P < .001) vs no history). Improved OS was observed among White Hispanics (WH) vs WNH (HR .73 [95%CI: .655-.817], P < .001) and women vs men (HR .88 [95%CI: .807-.954], P = .002). Geographical mapping showed that mortality rates were highest in census tracts with low income and education. CONCLUSION Our findings suggest that sociodemographic and clinical factors impact OS from hypopharyngeal/laryngeal cancer in Florida and vary geographically within the state. These results will help guide future public health interventions.
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Affiliation(s)
- Uche C. Ezeh
- Department of Otolaryngology–Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Abdurrahman Al-Awady
- Department of Otolaryngology–Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Ming Lee
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Garrett Forman
- Department of Otolaryngology–Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Sophia Peifer
- Department of Otolaryngology–Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Alana Deo
- University of California Santa Barbara, Santa Barbara, CA, USA
| | - Larissa Sweeny
- Department of Otolaryngology–Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Donald Weed
- Department of Otolaryngology–Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Erin K. Kobetz
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Isildinha M Reis
- Division of Biostatistics, Department of Public Health Sciences, Sylvester Biostatistics and Bioinformatics Shared Resource, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Elizabeth Franzmann
- Department of Otolaryngology–Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Unger JM, Xiao H, Vaidya R, LeBlanc M, Hershman DL. Medicaid Expansion of the Patient Protection and Affordable Care Act and Participation of Patients With Medicaid in Cancer Clinical Trials. JAMA Oncol 2023; 9:1371-1379. [PMID: 37590003 PMCID: PMC10436183 DOI: 10.1001/jamaoncol.2023.2800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 05/12/2023] [Indexed: 08/18/2023]
Abstract
Importance The Patient Protection and Affordable Care Act (ACA) Medicaid expansion resulted in increased use of Medicaid insurance nationwide. However, the association between Medicaid expansion and access to clinical trials has not been examined to date. Objective To examine whether the implementation of ACA Medicaid expansion was associated with increased participation of patients with Medicaid insurance in cancer clinical trials. Design, Setting, and Participants Data for this cohort study of 51 751 patients were from the SWOG Cancer Research Network. All patients aged 18 to 64 years and enrolled in treatment trials with Medicaid or private insurance between April 1, 1992, and February 29, 2020, were included. Interrupted time-series analysis with segmented logistic regression was used. The monthly unemployment rate and presidential administration were adjusted to reflect potential differences in Medicaid use associated with economic conditions and national administrative policies, respectively. Data analysis was conducted between June 22, 2021, and August 5, 2022. Exposure Implementation of Medicaid expansion on January 1, 2014, was the independent exposure variable. Main Outcomes and Measures The number and proportion of patients by insurance type enrolled in cancer clinical trials over time were analyzed. Results Overall, data for 51 751 patients were analyzed. Mean (SD) age was 50.6 (9.8) years, 67.3% of patients were female, 41.1% were younger than 50 years, and 9.1% used Medicaid. A 19% annual increase (odds ratio [OR], 1.19; 95% CI, 1.11-1.28; P < .001) was identified in the odds of patients using Medicaid after the ACA Medicaid expansion, resulting in a 52% increase (OR, 1.52; 95% CI, 1.29-1.78; P < .001) compared with what was expected in the number of Medicaid patients enrolled over time. The association was greater in states that adopted Medicaid expansion in 2014 to 2015 (OR, 1.26; 95% CI, 1.15-1.38; P < .001) compared with other states (OR, 1.08; 95% CI, 0.96-1.21; P = .20; P = .04 for interaction). By February 2020, the proportion of patients with Medicaid insurance was 17.8% (95% CI, 15.0%-20.8%; P < .001), whereas the expected proportion had ACA Medicaid expansion not occurred was 6.9% (95% CI, 4.4%-10.3%; P < .001). Conclusions and Relevance Findings suggest that implementation of ACA Medicaid expansion was associated with increased participation of patients using Medicaid in cancer clinical trials. Improved participation in clinical trials for Medicaid-insured patients is critical for socioeconomically vulnerable patients seeking access to the newest treatments available in trials and for improving confidence that trial findings apply to patients of all backgrounds.
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Affiliation(s)
- Joseph M. Unger
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Hong Xiao
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Riha Vaidya
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Michael LeBlanc
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Dawn L. Hershman
- Columbia University Irving Medical Center, Columbia University, New York, New York
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Semprini J. Examining the effect of Medicaid expansion on early detection of head and neck cancer of the oral cavity and pharynx by HPV-type and generosity of dental benefits. Cancer Rep (Hoboken) 2023; 6:e1840. [PMID: 37248803 PMCID: PMC10432424 DOI: 10.1002/cnr2.1840] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/09/2023] [Accepted: 05/22/2023] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND Over a decade of evidence supports the claim that increased access to insurance through Medicaid expansions improves early detection of cancer. Yet, evidence linking Medicaid expansions to early detection of head and neck cancers (HNC) of the oral cavity and pharynx, specifically, may be limited by the lack of attention to Human Papillomavirus (HPV) etiology, generosity of dental coverage, and valid inference analyzing state cancer registry data. AIMS This study reexamined the effect of Medicaid expansion on early detection of HPV+/- HNC in states offering extensive dental benefits. MATERIALS AND METHODS Specialized data from the Surveillance, Epidemiology, and End Results (SEER) program was analyzed to account for, previously unmeasurable, differential detection patterns of HNCs associated with HPV. Then, to identify the effect of increasing Medicaid eligibility on staging patterns in states offering extensive benefits amidst potentially non-common trends between states, a "Triple Differences" design identifies the differential effect of Medicaid Expansion (with dental coverage) on HPV-negative HNCs relative to the change in HPV-positive HNCs. For valid inference analyzing a small number of state clusters (12) in cancer registry data, each regression model applies a Wild Cluster Bootstrap. RESULTS Expanding Medicaid eligibility was found to be associated with a decrease in the proportion of distant-stage diagnoses of HPV(-) HNCs, but only among states which increased Medicaid dental generosity at the time of Medicaid expansion. CONCLUSIONS These results suggest that adding extensive Medicaid dental benefits was the primary mechanism impacting HNC detection. This study highlights the potential positive spillover effects of policies which increase access to public dental coverage for low-income adults, while also showing the limitation of access to dental services for improving early detection of HPV+ HNCs.
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Affiliation(s)
- Jason Semprini
- Department of Health Management and PolicyUniversity of Iowa College of Public HealthIowa CityIowaUSA
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Han C, Khan NI, Mady LJ. Prognosis. Otolaryngol Clin North Am 2023; 56:389-402. [PMID: 37030950 DOI: 10.1016/j.otc.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Prognosis is defined as the likely outcome or course of a disease and is the result of a complex interplay between patient and tumor factors. Unfortunately, the prognosis of patients with laryngeal cancer has not changed significantly over the past several decades. However, as our understanding of these patient and tumor factors becomes more nuanced and the resulting treatment options become more precise, there is the potential to improve the prognosis for these patients.
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Irace AL, Sharma RK, Smith TL, Stewart MG, Gudis DA. Impact of Medicaid Expansion on Rhinologic Cancer Presentation, Treatment, and Outcomes. Laryngoscope 2023; 133:43-50. [PMID: 35147223 DOI: 10.1002/lary.30049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/11/2022] [Accepted: 01/22/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The United States Patient Protection and Affordable Care Act allocated funds for states to expand Medicaid coverage. However, several states declined expansion. We aim to determine whether Medicaid expansion is associated with healthcare coverage, cancer stage at diagnosis, treatment, and survival among patients with rhinologic cancer. Rhinologic cancer was defined to include cancer of the nasal cavity, paranasal sinus, nasopharynx, or olfactory nerve. STUDY DESIGN Cohort study. METHODS Patients diagnosed with primary rhinologic malignancies between 2007 to 2016 were extracted from the National Cancer Institute Surveillance, Epidemiology, End Results (SEER) registry. Patients were grouped by diagnosis before and after 2014 (when Medicaid expansion became effective) and whether their state had expanded Medicaid. Multivariable logistic regression controlling for age, sex, race, ethnicity, and income/education was utilized to examine associations between Medicaid expansion/insurance status and stage at diagnosis, treatment, and survival. Overall and disease-specific survival were examined using Kaplan-Meier analysis. RESULTS Analysis included 10,164 patients. The proportion of uninsured patients decreased after 2014 (2.4%) compared to before 2014 (4.8%, P < .001). After 2014, patients in nonexpanded states were more likely to be diagnosed with advanced stage disease compared to patients in expanded states (N = 2,364; OR = 1.27, 95% CI 1.01-1.60). Being uninsured in any state was associated with advanced stage disease at diagnosis (OR = 1.75, 95% CI 1.41-2.22) and increased risk of disease-specific death (HR = 1.54, 95% CI 1.32-1.82). Survival measures were not associated with diagnosis before versus after 2014 or Medicaid expansion. CONCLUSIONS Patients lacking insurance or residing in nonexpanded states may be more likely to present with advanced stage rhinologic cancer. Longitudinal studies should validate these findings. LEVEL OF EVIDENCE 3 Laryngoscope, 133:43-50, 2023.
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Affiliation(s)
- Alexandria L Irace
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, U.S.A
| | - Rahul K Sharma
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, U.S.A
| | - Timothy L Smith
- Department of Otolaryngology-Head and Neck Surgery, Oregon Sinus Center, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Michael G Stewart
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, New York, U.S.A
| | - David A Gudis
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, U.S.A
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Yu B, Lin F, Duan J, Ning H. The influence of marital status on survival in patients with nasopharyngeal carcinoma: A surveillance, epidemiology, and end results database analysis. Medicine (Baltimore) 2022; 101:e30516. [PMID: 36086732 PMCID: PMC10980364 DOI: 10.1097/md.0000000000030516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 08/05/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND To assess the influence of marital status on the survival of patients with nasopharyngeal carcinoma (NPC), we used the Surveillance, Epidemiology, and End Results (SEER) database to analyze 5477 patients who were diagnosed with NPC from 2004 to 2016. METHODS Kaplan-Meier survival analysis and Cox proportional hazard regression were used to analyze the influence of marital status on cause-specific survival (CSS) and overall survival (OS). Subgroup analyses was used to assess the influence of marital status on CSS based on different factors. RESULTS For the 5477 patients, 61.5%, 22.4%, and 16.1% were married, single/unmarried, and separated/widowed/divorced, respectively. The separated/widowed/divorced group was more likely to be female (P < .001), had the highest proportion of elderly subjects (P < .001), were mostly Caucasian (P < .001), had pathological grade I/II (P < .001), were likely to undergo surgery (P = .032), and were registered in the northeast, north-central, and south (P < .001) regions. The 5-year CSS rates were 92.6%, 92.4%, and 85.1% in the married, single/unmarried, and separated/widowed/divorced groups, respectively (P < .001), and the 5-year OS rates were 60.7%, 54.6%, and 40.1%, respectively (P < .001). CONCLUSION Marital status is an independent prognostic factor of NPC. Separated/widowed/divorced patients had a significantly increased risk of NPC-related death (hazard ratio [HR] = 2.180, 95% confidence interval [CI] 1.721-2.757, P < .001) compared to married patients. The single/unmarried (P = .355) group had a CSS similar to that of the unmarried group. Marital status is an independent prognostic factor of survival in NPC patients. Separated/widowed/divorced status increases the risk of NPC mortality.
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Affiliation(s)
- Bin Yu
- Department of Pharmacy, Mianyang Central Hospital, Mianyang, P.R. China
| | - Fei Lin
- Department of Pharmacy, The First Affiliated Hospital of Chengdu Medical College, Clinical Medical College, Chengdu Medical College, Chengdu, P.R. China
| | - Jie Duan
- Department of Clinical Pharmacy, Pidu District People’s Hospital, Chengdu, P.R. China
| | - Hong Ning
- Department of Pharmacy, Mianyang Central Hospital, Mianyang, P.R. China
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Al‐Qurayshi Z, Sullivan CB, Shama MA, Pagedar NA, Kandil E. The Impact of Medicaid Expansion on Head and Neck Malignancies Presentation and Survival. Laryngoscope 2022; 133:1409-1414. [PMID: 37158264 DOI: 10.1002/lary.30314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 06/06/2022] [Accepted: 07/06/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Under the Affordable Care Act (ACA), Medicaid expansion became effective in states that have adopted it. We aim to examine its impact on head and neck cancers. METHODS A retrospective study that utilizes the Surveillance, Epidemiology, and End Results database, 2010-2016. Study population included patients with head and neck squamous cell carcinoma (HNSCC), differentiated thyroid carcinoma, and head and neck cutaneous melanoma. The objective is to examine disease-specific survival before and after Medicaid expansion. RESULTS In states that adopted Medicaid expansion, the ratio of Medicaid: uninsured patients increased from 3:1 to 9:1 (p < 0.001). In states that did not adopt Medicaid expansion, the ratio increased from 1:1 to 2:1 (p < 0.001), making the increase in Medicaid coverage in states that adopted the expansion significantly higher (p < 0.001). Patients diagnosed with HNSCC before the expansion had worse survival (hazard ratio [HR]: 1.24, 95% confidence interval: 1.11, 1.39, p < 0.001) in states that adopted Medicaid expansion. CONCLUSIONS Early data indicate that implementation of ACA improved disease-specific survival of patients with HNSCC. LEVEL OF EVIDENCE 3 Laryngoscope, 133:1409-1414, 2023.
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Affiliation(s)
- Zaid Al‐Qurayshi
- Department of Otolaryngology–Head and Neck Surgery University of Iowa Hospitals and Clinics Iowa City Iowa U.S.A
| | | | - Mohamed A. Shama
- Department of Surgery Tulane University School of Medicine New Orleans Louisiana U.S.A
| | - Nitin A. Pagedar
- Department of Otolaryngology–Head and Neck Surgery University of Iowa Hospitals and Clinics Iowa City Iowa U.S.A
| | - Emad Kandil
- Department of Surgery Tulane University School of Medicine New Orleans Louisiana U.S.A
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13
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Minetos PD, Karamian BA, Kothari P, Jeyamohan H, Canseco JA, Patel PD, Thaete L, Singh A, Campbell D, Kaye ID, Woods BI, Kurd MF, Rihn JA, Anderson DG, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Impact of the Affordable Care Act on Insurance Status of Spine Patients Presenting to the Emergency Department. Am J Med Qual 2022; 37:207-213. [PMID: 34787591 DOI: 10.1097/jmq.0000000000000027] [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: 11/26/2022]
Abstract
Although the Affordable Care Act (ACA) has been shown to broadly affect access to care, there is little data examining the change in insurance status with regard to nonelective spinal trauma, infection, and tumor patients. The purpose of this study is to evaluate the changes in insurance status before and after implementation of the ACA in patients who present to the emergency room of a single, level 1 trauma and regional spinal cord injury center. Patient demographic and hospital course information were derived from consult notes and electronic medical record review. Spinal consults between January 1, 2013, and December 31, 2015, were initially included. Consults between January 1 and December 31, 2014, were subsequently removed to obtain two separate cohorts reflecting one calendar year prior to ("pre-ACA") and following ("post-ACA") the effective date of implementation of the ACA on January 1, 2014. Compared with the pre-ACA cohort, the post-ACA cohort had a significant increase in insurance coverage (95.0% versus 83.9%, P < 0.001). Post-ACA consults had a significantly shorter length of stay compared with pre-ACA consults (7.94 versus 9.19, P < 0.001). A significantly greater percentage of the post-ACA cohort appeared for clinical follow-up subsequent to their initial consultation compared to the pre-ACA cohort (49.5% versus 35.3%, P < 0.001). Spinal consultation after the implementation of the ACA was found to be a significant positive predictor of Medicaid coverage (odds ratio = 1.96 [1.05, 3.82], P = 0.04) and a significant negative predictor of uninsured status (odds ratio = 0.28 [0.16, 0.47], P < 0.001). Increase in overall insurance coverage, increase in patient follow-up after initial consultation, and decrease in hospital length of stay were all noted after the implementation of the ACA for spinal consultation patients presenting to the emergency department.
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Affiliation(s)
- Paul D Minetos
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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14
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Nallani R, Subramanian TL, Ferguson-Square KM, Smith JB, White J, Chiu AG, Francis CL, Sykes KJ. A Systematic Review of Head and Neck Cancer Health Disparities: A Call for Innovative Research. Otolaryngol Head Neck Surg 2022; 166:1238-1248. [PMID: 35133913 DOI: 10.1177/01945998221077197] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE (1) Describe the existing head and neck cancer health disparities literature. (2) Contextualize these studies by using the NIMHD research framework (National Institute on Minority Health and Health Disparities). (3) Explore innovative ideas for further study and intervention. DATA SOURCES Ovid MEDLINE, Embase, Web of Science, and Google Scholar. REVIEW METHODS Databases were systematically searched from inception to April 20, 2020. The PRISMA checklist was followed (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Two authors reviewed all articles for inclusion. Extracted data included health disparity population and outcomes, study details, and main findings and recommendations. Articles were also classified per the NIMHD research framework. RESULTS There were 148 articles included for final review. The majority (n = 104) focused on health disparities related to at least race/ethnicity. Greater than two-thirds of studies (n = 105) identified health disparities specific to health behaviors or clinical outcomes. Interaction between the individual domain of influence and the health system level of influence was most discussed (n = 99, 66.9%). Less than half of studies (n = 61) offered specific recommendations or interventions. CONCLUSIONS There has been extensive study of health disparities for head and neck cancer, largely focusing on individual patient factors or health care access and quality. This review identifies gaps in this research, with large numbers of retrospective database studies and little discussion of potential contributors and explanations for these disparities. We recommend shifting research on disparities upstream toward a focus on community and societal factors, rather than individual, and an evaluation of interventions to promote health equity.
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Affiliation(s)
- Rohit Nallani
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | | | - Joshua B Smith
- Department of Otolaryngology-Head and Neck Surgery, St Louis University, St Louis, Missouri, USA
| | - Jacob White
- Research and Learning, A.R. Dykes Library, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Alexander G Chiu
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Carrie L Francis
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Kevin J Sykes
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
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15
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Entezami P, Thomas B, Mansour J, Asarkar A, Nathan C, Pang J. Targets for improving disparate head and neck cancer outcomes in the low-income population. Laryngoscope Investig Otolaryngol 2021; 6:1481-1488. [PMID: 34938891 PMCID: PMC8665427 DOI: 10.1002/lio2.698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 11/02/2021] [Indexed: 11/30/2022] Open
Abstract
Low-income patients have worse head and neck cancer outcomes than those with high-income. Yet, few targets have been identified to specifically improve outcomes in the low-income population. Here, we conduct a review on the current literature on head and neck cancer outcomes in the low-income population and identify targets for intervention. The degree of disparity is in the range of 20%-90% worse overall survival in the low-income population. Eliminating smoking would have the greatest effect on head and neck cancer mortality rates in the low-income population. Additionally, access to oral cancer exams, assistance with transportation, and continued expansion of telemedicine would facilitate early diagnosis and timely treatment in patients who develop head and neck cancer.
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Affiliation(s)
- Payam Entezami
- Louisiana State University Shreveport Medical Center ShreveportShreveportLouisianaUSA
| | - Bennett Thomas
- Louisiana State University Shreveport Medical Center ShreveportShreveportLouisianaUSA
| | - Jobran Mansour
- Louisiana State University Shreveport Medical Center ShreveportShreveportLouisianaUSA
| | - Ameya Asarkar
- Louisiana State University Shreveport Medical Center ShreveportShreveportLouisianaUSA
| | - Cherie‐Ann Nathan
- Louisiana State University Shreveport Medical Center ShreveportShreveportLouisianaUSA
| | - John Pang
- Louisiana State University Shreveport Medical Center ShreveportShreveportLouisianaUSA
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16
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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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17
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Liu B, Ornstein KA, Alpert N, Schwartz RM, Dharmarajan KV, Kelley AS, Taioli E. Trends of hospitalizations among patients with both cancer and dementia diagnoses in New York 2007-2017. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2021; 9:100565. [PMID: 34252707 PMCID: PMC8453053 DOI: 10.1016/j.hjdsi.2021.100565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 05/25/2021] [Accepted: 07/05/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Cancer and dementia have often been studied in isolation. We aimed to examine the spatiotemporal trend of inpatient admissions with both cancer and dementia diagnoses. METHODS Using state-wide inpatient claims data, we identified all hospital admissions for patients aged ≥50 years with both cancer and dementia diagnoses in New York State, 2007-2017. We examined the spatiotemporal trend of the admission using a novel Bayesian hierarchical model adjusting for socioeconomic factor, as measured by Yost index. RESULTS Admissions with the presence of both cancer and dementia diagnoses represented 8.5% of all admissions with a cancer diagnosis, and the proportion increased from 7.1% in 2007 to 9.7% in 2017. The median admission rate was 3.5 (interquartile range: 2.2-5.2) hospitalizations per 1000 population aged ≥50 years, which increased from 2.9 in 2007 to 3.7 in 2017. The admission rate peaked first in 2010 followed by a smaller peak in 2014, before stabilizing at a level higher than the pre-2010 period. Taking into account the spatiotemporal heterogeneity, we found that hospitalizations among those with both cancer and dementia diagnoses were associated with a higher socioeconomic status (the posterior median relative risk for Yost index = 1.046 (95% credible interval: 1.033-1.058)). CONCLUSIONS Hospitalizations of patients with both cancer and dementia increased over time. Cancer care providers and healthcare systems should be prepared to provide prevention and management strategies and engage in complex medical decision-making for this increasingly common patient population comprised of individuals with cancer and dementia.
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Affiliation(s)
- Bian Liu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Katherine A Ornstein
- Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Naomi Alpert
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rebecca M Schwartz
- Department of Occupational Medicine, Epidemiology and Prevention, Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Kavita V Dharmarajan
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Amy S Kelley
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Emanuela Taioli
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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18
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da Cunha AR, Bigoni A, Antunes JLF, Hugo FN. The impact of inequalities and health expenditure on mortality due to oral and oropharyngeal cancer in Brazil. Sci Rep 2021; 11:12845. [PMID: 34145332 PMCID: PMC8213849 DOI: 10.1038/s41598-021-92207-x] [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: 12/15/2020] [Accepted: 06/07/2021] [Indexed: 11/30/2022] Open
Abstract
This study aims to assess the magnitude and trend of mortality rates due to oral (OC) and oropharyngeal cancer (OPC) in the 133 Intermediate Geographic Regions (IGR) of Brazil between 1996 and 2018 and to analyze its association with sociodemographic variables and provision of health services. It also aims to compare the trend of mortality from neoplasms that have been reported as associated with HPV (OPC) with the trend of neoplasms that have been reported as not associated with HPV (OC). We obtained mortality data from the Mortality Information System in Brazil and analyzed the trends using the Prais-Winsten method. Then, we assessed the relationship between mortality trends and socioeconomic, health spending, and health services provision variables. The median of the annual percent change of the country’s mortality rates was 0.63% for OC and 0.83% for OPC. Trends in mortality in the IGRs correlated significantly with the Human Development Index and government expenditure on ambulatory health care and hospitalizations. Mortality from both types of cancer decreased in those IGR in which the government spent more on health and in the more socioeconomically developed ones. This study found no epidemiological indication that HPV plays the leading etiological factor in OPC in Brazil.
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Affiliation(s)
- Amanda Ramos da Cunha
- Faculty of Dentistry, Federal University of Rio Grande do Sul, 2492 Ramiro Barcelos St, Porto Alegre, RS, 90035-003, Brazil.
| | - Alessandro Bigoni
- School of Public Health, University of São Paulo, 715 Doutor Arnaldo Ave, São Paulo, SP, 01246-904, Brazil
| | | | - Fernando Neves Hugo
- Faculty of Dentistry, Federal University of Rio Grande do Sul, 2492 Ramiro Barcelos St, Porto Alegre, RS, 90035-003, Brazil
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Kronenfeld JP, Ryon EL, Goldberg D, Lee RM, Yopp A, Wang A, Lee AY, Luu S, Hsu C, Silberfein E, Russell MC, Merchant NB, Goel N. Survival inequity in vulnerable populations with early-stage hepatocellular carcinoma: a United States safety-net collaborative analysis. HPB (Oxford) 2021; 23:868-876. [PMID: 33487553 PMCID: PMC8205960 DOI: 10.1016/j.hpb.2020.11.1150] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/12/2020] [Accepted: 11/24/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Access to health insurance and curative interventions [surgery/liver-directed-therapy (LDT)] affects survival for early-stage hepatocellular carcinoma (HCC). The aim of this multi-institutional study of high-volume safety-net hospitals (SNHs) and their tertiary-academic-centers (AC) was to identify the impact of type/lack of insurance on survival disparities across hospitals, particularly SNHs whose mission is to minimize insurance related access-to-care barriers for vulnerable populations. METHODS Early-stage HCC patients (2012-2014) from the US Safety-Net Collaborative were propensity-score matched by treatment at SNH/AC. Overall survival (OS) was the primary outcome. Multivariable Cox proportional-hazard analysis was performed accounting for sociodemographic/clinical parameters. RESULTS Among 925 patients, those with no insurance (NI) had decreased curative surgery, compared to those with government insurance (GI) and private insurance [PI, (PI-SNH:60.5% vs. GI-SNH:33.1% vs. NI-SNH:13.6%, p < 0.001)], and decreased median OS (PI-SNH:32.1 vs. GI-SNH:22.8 vs. NI-SNH:9.4 months, p = 0.002). On multivariable regression controlling for sociodemographic/clinical parameters, NI-SNH (HR:2.5, 95% CI:1.3-4.9, p = 0.007) was the only insurance type/hospital system combination with significantly worse OS. CONCLUSION NI-SNH patients received less curative treatment than other insurance/hospitals types suggesting that treatment barriers, beyond access-to-care, need to be identified and addressed to achieve survival equity in early-stage HCC for vulnerable populations (NI-SNH).
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Affiliation(s)
- Joshua P Kronenfeld
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL 33136, USA
| | - Emily L Ryon
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL 33136, USA
| | - David Goldberg
- Division of Digestive Health and Liver Disease, Department of Medicine, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136, USA
| | - Rachel M Lee
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, 1365-C Clifton Road NE Atlanta, 30322, Georgia
| | - Adam Yopp
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical School, 2201 Inwood Rd 3rd Floor Suite 500, Dallas, TX 75390, USA
| | - Annie Wang
- Division of Surgical Oncology, Department of Surgery, NYU Langone Health, 160 East 34th Street, 3rd Floor, New York, NY, 10016, USA
| | - Ann Y Lee
- Division of Surgical Oncology, Department of Surgery, NYU Langone Health, 160 East 34th Street, 3rd Floor, New York, NY, 10016, USA
| | - Sommer Luu
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Cary Hsu
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Eric Silberfein
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Maria C Russell
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, 1365-C Clifton Road NE Atlanta, 30322, Georgia
| | - Nipun B Merchant
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL 33136, USA
| | - Neha Goel
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL 33136, USA.
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20
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Pannu JS, Simpson MC, Adjei Boakye E, Massa ST, Cass LM, Challapalli SD, Rohde RL, Osazuwa-Peters N. Survival outcomes for head and neck patients with Medicaid: A health insurance paradox. Head Neck 2021; 43:2136-2147. [PMID: 33780066 DOI: 10.1002/hed.26682] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 01/11/2021] [Accepted: 03/12/2021] [Indexed: 11/05/2022] Open
Abstract
PURPOSE Privately insured patients with head and neck cancer (HNC) typically have better outcomes; however, differential outcome among Medicaid versus the uninsured is unclear. We aimed to describe outcome disparities among HNC patients uninsured versus on Medicaid. METHODS A cohort of 18-64-year-old adults (n = 57 920) with index HNC from the Surveillance, Epidemiology, and End Results 18 database (2007-2015) was analyzed using Fine and Gray multivariable competing risks proportional hazards models for HNC-specific mortality. RESULTS Medicaid (sdHR = 1.65, 95% CI 1.58, 1.72) and uninsured patients (sdHR = 1.55, 95% CI 1.46, 1.65) had significantly greater mortality hazard than non-Medicaid patients. Medicaid patients had increased HNC mortality hazard than those uninsured. CONCLUSION Compared with those uninsured, HNC patients on Medicaid did not have superior survival, suggesting that there may be underlying mechanisms/factors inherent in this patient population that could undermine access to care benefits from being on Medicaid.
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Affiliation(s)
- Jaibir S Pannu
- Saint Louis University School of Medicine, Saint Louis, Missouri, USA
| | - Matthew C Simpson
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, Saint Louis, Missouri, USA
| | - Eric Adjei Boakye
- Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, Illinois, USA.,Simmons Cancer Center, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Sean T Massa
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, Saint Louis, Missouri, USA
| | - Lauren M Cass
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, Saint Louis, Missouri, USA
| | - Sai D Challapalli
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas, USA
| | - Rebecca L Rohde
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nosayaba Osazuwa-Peters
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Cancer Center, Duke University School of Medicine, Durham, North Carolina, USA
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21
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Malik AT, Alexander J, Khan SN, Scharschmidt TJ. Has the Affordable Care Act Been Associated with Increased Insurance Coverage and Early-stage Diagnoses of Bone and Soft-tissue Sarcomas in Adults? Clin Orthop Relat Res 2021; 479:493-502. [PMID: 32805094 PMCID: PMC7899708 DOI: 10.1097/corr.0000000000001438] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 07/08/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment of bone and soft-tissue sarcomas can be costly, and therefore, it is not surprising that insurance status of patients is a prognostic factor in determining overall survival. Furthermore, uninsured individuals with suspected bone and/or soft-tissue masses routinely encounter difficulty in obtaining access to basic healthcare (such as office visits, radiology scans), and therefore are more likely to be diagnosed with later stages at presentation. The Patient Protection and Affordable Care Act (ACA) mandate of 2010 aimed to increase access to care for uninsured individuals by launching initiatives, such as expanding Medicaid eligibility, subsidizing private insurance, and developing statewide mandates requiring individuals to have a prescribed minimum level of health insurance. Although prior reports have demonstrated that the ACA increased both coverage and the proportion of early-stage diagnoses among patients with common cancers (including breast, colon, prostate, and lung), it is unknown whether similar improvements have occurred for patients with bone and soft-tissue sarcomas. Understanding changes in insurance coverages and stage at diagnosis of patients with bone and soft-tissue sarcomas would be paramount in establishing policies that will ensure orthopaedic cancer care is made equitable and accessible to all. QUESTIONS/PURPOSES (1) Has the introduction of the ACA been associated with changes in insurance coverage for adult patients with newly diagnosed bone and soft-tissue sarcomas? (2) Did the introduction of health reforms under the ACA lead to an increased proportion of sarcoma diagnoses occurring at earlier disease stages? METHODS The 2007 to 2015 Surveillance, Epidemiology and End Results database was queried using International Classification of Diseases for Oncology codes for primary malignant bone tumors of the upper and lower extremity (C40.0 to C40.3), unspecified or other overlapping bone, articular cartilage, and joint and/or ribs, sternum, or clavicle (C40.8 to C40.9, C41.3, and C41.8 to C41.9), vertebral column (C41.2), pelvis (C41.4, C41.8, and C41.9), and soft-tissue sarcomas of the upper or lower extremity and/or pelvis (C49.1, C49.2, and C49.5). A total of 15,287 patients with newly diagnosed cancers were included, of which 3647 (24%) were malignant bone tumors and 11,640 (76%) were soft-tissue sarcomas. The study sample was divided into three cohorts according to specified time periods: pre-ACA from 2007 to 2010 (6537 patients), pre-Medicaid expansion from 2011 to 2013 (5076 patients), and post-Medicaid expansion from 2014 to 2015 (3674 patients). The Pearson chi square tests were used to assess for changes in the proportion of Medicaid and uninsured patients across the specified time periods: pre-ACA, pre-expansion and post-expansion. A differences-in-differences analysis was also performed to assess changes in insurance coverage for Medicaid and uninsured patients among states that chose to expand Medicaid coverage in 2014 under the ACA's provision versus those who opted out of Medicaid expansion. Since the database switched to using the American Joint Commission on Cancer (AJCC) 7th edition staging system in 2010, linear regression using data only from 2010 to 2015 was performed that assessed changes in cancer stage at diagnosis from 2010 to 2015 alone. After stratifying by cancer type (bone or soft-tissue sarcoma), Pearson chi square tests were used to assess for changes in the proportion of patients who were diagnosed with early, late, and unknown stage at presentation before Medicaid expansion (2011-2013) and after Medicaid expansion (2014-2015) among states that chose to expand versus those who did not. RESULTS After stratifying by time cohorts: pre-ACA (2007 to 2010), pre-expansion (2011 to 2013) and post-expansion (2014 to 2015), we observed that the most dramatic changes occurred after Medicaid eligibility was expanded (2014 onwards), with Medicaid proportions increasing from 12% (pre-expansion, 2011 to 2013) to 14% (post-expansion, 2014 to 2015) (p < 0.001) and uninsured proportions decreasing from 5% (pre-expansion, 2011 to 2013) to 3% (post-expansion, 2014 to 2015) (p < 0.001). A differences-in-differences analysis that assessed the effect of Medicaid expansion showed that expanded states had an increase in the proportion of Medicaid patients compared with non-expanded states, (3.6% [95% confidence interval 0.4 to 6.8]; p = 0.03) from 2014 onwards. For the entire study sample, the proportion of early-stage diagnoses (I/II) increased from 56% (939 of 1667) in 2010 to 62% (1137 of 1840) in 2015 (p = 0.003). Similarly, the proportion of unknown stage diagnoses decreased from 11% (188 of 1667) in 2010 to 7% (128 of 1840) in 2015 (p = 0.002). There was no change in proportion of late-stage diagnoses (III/IV) from 32% (540 of 1667) in 2010 to 31% (575 of 1840) in 2015 (p = 0.13). CONCLUSION Access to cancer care for patients with primary bone or soft-tissue sarcomas improved after the ACA was introduced, as evidenced by a decrease in the proportion of uninsured patients and corresponding increase in Medicaid coverage. Improvements in coverage were most significant among states that adopted the Medicaid expansion of 2014. Furthermore, we observed an increasing proportion of early-stage diagnoses after the ACA was implemented. The findings support the preservation of the ACA to ensure cancer care is equitable and accessible to all vulnerable patient populations. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Azeem Tariq Malik
- A. T. Malik, J. Alexander, S. N. Khan, T. J. Scharschmidt, The James Cancer Hospital and Solove Research Institute, the Ohio State University Wexner Medical Center, Columbus, OH, USA
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22
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Sineshaw HM, Ellis MA, Yabroff KR, Han X, Jemal A, Day TA, Graboyes EM. Association of Medicaid Expansion Under the Affordable Care Act With Stage at Diagnosis and Time to Treatment Initiation for Patients With Head and Neck Squamous Cell Carcinoma. JAMA Otolaryngol Head Neck Surg 2021; 146:247-255. [PMID: 31944232 DOI: 10.1001/jamaoto.2019.4310] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Medicaid expansions as part of the Patient Protection and Affordable Care Act (ACA) are associated with decreases in the percentage of uninsured patients who have received a new diagnosis of cancer. Little is known about the association of Medicaid expansions with stage at diagnosis and time to treatment initiation (TTI) for patients with head and neck squamous cell carcinoma (HNSCC). Objective To determine the association of Medicaid expansions as part of the ACA with stage at diagnosis and TTI for patients with HNSCC. Design, Setting, and Participants A retrospective cohort study was conducted at Commission on Cancer-accredited facilities among 90 789 patients identified from the National Cancer Database aged 18 to 64 years with HNSCC that was diagnosed during the period from January 1, 2010, to December 31, 2016. Statistical analysis was conducted from February 18 to November 8, 2019. Main Outcomes and Measures Outcome measures included health insurance coverage, stage at diagnosis, and TTI. Absolute percentage change in health insurance coverage, crude and adjusted difference in differences (DD) in absolute percentage change in coverage, stage at diagnosis, and TTI before (2010-2013) and after (2014-2016) ACA implementation were calculated for Medicaid expansion and nonexpansion states. Results Of the 90 789 nonelderly adults with newly diagnosed HNSCC (mean [SD] age, 54.7 [7.0] years), 70 907 (78.1%) were men, 72 911 (80.3%) were non-Hispanic white, 52 142 (57.4%) were between 55 and 64 years of age, and 54 940 (60.5%) resided in states with an ACA Medicaid expansion. Compared with nonexpansion states, the percentage of patients with HNSCC with Medicaid increased more in expansion states after the implementation of the ACA (adjusted DD, 4.6 percentage points [95% CI, 3.7-5.4 percentage points]). The percentage of patients with localized disease (American Joint Committee on Cancer stage I-II) at diagnosis increased in expansion states compared with nonexpansion states for the overall cohort (adjusted DD, 2.3 percentage points [95% CI, 1.1-3.5 percentage points]) and for the subset of patients with nonoropharyngeal HNSCC (adjusted DD, 3.4 percentage points [95% CI, 1.5-5.2 percentage points]). The mean TTI did not differ between expansion and nonexpansion states for the cohort (adjusted DD, -12.7 percentage points [95% CI, -27.4 to 4.2 percentage points]) but improved for patients with nonoropharyngeal HNSCC (adjusted DD, -26.5 percentage points [95% CI, -49.6 to -3.4 percentage points]). Conclusions and Relevance This study suggests that Medicaid expansions were associated with a greater increase in the percentage of patients with HNSCC with Medicaid coverage, an increase in the percentage of patients with localized disease at diagnosis for the overall cohort of patients with HNSCC, and improved TTI for patients with nonoropharyngeal HNSCC.
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Affiliation(s)
- Helmneh M Sineshaw
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Mark A Ellis
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston
| | - K Robin Yabroff
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Xuesong Han
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Ahmedin Jemal
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Terry A Day
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston.,Hollings Cancer Center, Medical University of South Carolina, Charleston
| | - Evan M Graboyes
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston.,Hollings Cancer Center, Medical University of South Carolina, Charleston
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23
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Panth N, Barnes J, Sethi RKV, Varvares MA, Osazuwa-Peters N. Socioeconomic and Demographic Variation in Insurance Coverage Among Patients With Head and Neck Cancer After the Affordable Care Act. JAMA Otolaryngol Head Neck Surg 2021; 145:1144-1149. [PMID: 31670798 DOI: 10.1001/jamaoto.2019.2724] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Importance Health insurance status has a significant association with early diagnosis and stage at presentation, which are the most important predictors of survival among patients with head and neck cancer (HNC). Literature on the association of the Patient Protection and Affordable Care Act (ACA) with changes in insurance status among patients with HNC remains limited. To our knowledge, no studies have evaluated changes in insurance rates across sociodemographic subgroups of patients with HNC. Objective To assess the association of the implementation of the ACA with insurance status across socioeconomic and demographic subpopulations of patients with HNC. Design, Setting, and Participants A retrospective cohort study using data from the National Cancer Database (NCDB), a hospital-based cancer registry (2011-2015) for adults diagnosed with a malignant primary HNC was carried out. The analyses were conducted from November 2018 through December 2018. Main Outcomes and Measures Changes in the percentage of patients with insurance. Results A total of 131 779 patients with HNC were identified in the pre-ACA (77 071) and post-ACA (54 708) periods. Overall, 98 207 (74.5%) participants were men and 33 572 (25.5) were women, with 73 124 (55.5%) being aged between 50 to 64 years. There was a 2.68 percentage point decrease (PPD) (95% CI, 2.93-2.42) in the percentage of patients with HNC without insurance from the pre-ACA to the post-ACA period. Changes in the percentage of uninsured patients varied significantly by age, with the largest reduction in uninsured status among patients with HNC aged 18 to 34 years (5.12 PPD; 95% CI, 3.18-7.06) and the smallest reduction in uninsured among those aged 65 to 74 years (0.24 PPD; 95% CI, 0.03-0.45). There was a significantly greater reduction in uninsured status in low-income zip codes (3.45 PPD; 95% CI, 2.76-4.14) than in high-income zip codes (1.99 PPD; 95% CI, 1.63-2.36). Conclusions and Relevance There was a significant association between ACA implementation and percentage decrease in uninsured patients. Young adults and those residing in low-income zip codes experienced a significantly higher rate of insurance uptake compared with older adults and residents of high-income areas. This suggests that coverage expansions enacted through the ACA are not only associated with increased access to care among the broader HNC population, but that they may also yield a greater benefit among subpopulations with historically limited insurance coverage.
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Affiliation(s)
- Neelima Panth
- Duke University School of Medicine, Durham, North Carolina
| | - Justin Barnes
- St Louis University School of Medicine, St Louis, Missouri
| | - Rosh K V Sethi
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Mark A Varvares
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
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24
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Marks JA, Switchenko JM, Steuer CE, Ryan M, Patel MR, McDonald MW, Higgins K, Beitler JJ, Shin DM, Gillespie TW, Saba NF. Socioeconomic Factors Influence the Impact of Tumor HPV Status on Outcome of Patients With Oropharyngeal Squamous Cell Carcinoma. JCO Oncol Pract 2021; 17:e313-e322. [PMID: 33434083 DOI: 10.1200/op.20.00671] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE Human papilloma virus (HPV) association remains one of the most important predictors of clinical outcome in oropharyngeal squamous cell carcinoma (OPSCC). We aimed to determine whether the relationship between HPV status and overall survival was influenced by socioeconomic factors. MATERIALS AND METHODS Using the National Cancer Database, we examined the relationship between socioeconomic status and overall survival, controlling for demographics and socioeconomic variables (age at diagnosis, race, sex, clinical stage, facility type, facility location, insurance status, median-income quartiles, percent of no high-school education quartiles, rural-urban dwelling, Charlson-Deyo score, primary site, and treatment type). RESULTS HPV-positive patients with private insurance have improved overall survival compared with HPV-positive patients who are uninsured (hazard ratio [HR], 0.51, 95% CI, 0.41 to 0.63, P < .001). HPV-negative patients with private insurance have improved overall survival compared with HPV-negative patients who were uninsured (HR, 0.62, 95% CI, 0.53 to 0.73, P < .001). HPV-positive patients living in the south had improved overall survival compared with HPV-positive patients living in the west (HR, 0.83, 95% CI, 0.72 to 0.96, P = .013). As assessed through interaction, relationships between survival and insurance (P = .004), rural-urban status (P = .009), and facility location (P = .021) statistically differed between HPV-positive and HPV-negative patients. CONCLUSION HPV status impact on overall survival for patients with OPSCC is influenced by socioeconomic factors including insurance status and treatment facility. A deeper understanding of these interactions is needed to improve equity of care for patients with OPSCC.
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Affiliation(s)
- Jennifer A Marks
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA
| | - Jeffrey M Switchenko
- Department of Biostatistics & Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Conor E Steuer
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA
| | - Martha Ryan
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA
| | - Mihir R Patel
- Department of Otolaryngology, Emory University School of Medicine, Atlanta, GA
| | - Mark W McDonald
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA
| | - Kristin Higgins
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA
| | - Johnathan J Beitler
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA.,Department of Otolaryngology, Emory University School of Medicine, Atlanta, GA.,Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA
| | - Dong M Shin
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA
| | | | - Nabil F Saba
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA
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25
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Gadkaree SK, McCarty JC, Feng AL, Siu JM, Burks CA, Deschler DG, Richmon JD, Varvares MA, Bergmark RW. Role of physician density in predicting stage and survival for head and neck squamous cell carcinoma. Head Neck 2020; 43:438-448. [PMID: 33015935 DOI: 10.1002/hed.26495] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 08/17/2020] [Accepted: 09/22/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Identifying and linking barriers to access to head and neck cancer care, specifically provider density, to stage of diagnosis and survival outcomes is important to serve as a foundation for policy interventions. METHODS Retrospective cohort study using patients with head and neck squamous cell (HNSCC) in the Surveillance, Epidemiology, and End Results (SEER) database from 2007 to 2016 and Area Resource File. Primary outcomes included stage of presentation and cancer-specific 5-year survival and relation to provider density. RESULTS The initial cohort consisted of 18 342 patients with oral cavity, 21 809 oropharyngeal, 15 860 laryngeal, and 2887 patients with hypopharyngeal malignancy. Non-Hispanic Black race and being uninsured increased the odds of presenting with advanced stage HNSCC and increased hazard of death. There was no significant and consistent association identified between Health Service Areas provider density and advanced stage at diagnosis or cancer-specific 5-year mortality. CONCLUSIONS Provider density of otolaryngologists and primary care physicians and dentists was not significantly associated with stage of presentation or cancer-specific survival for HNSCC while race and insurance status remained independent predictors for worse outcomes.
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Affiliation(s)
- Shekhar K Gadkaree
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Justin C McCarty
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Allen L Feng
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jennifer M Siu
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Otolaryngology, University of Toronto, Toronto, Ontario, USA
| | - Ciersten A Burks
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel G Deschler
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mark A Varvares
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Regan W Bergmark
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
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26
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Is Surgical Resection of the Primary Site Associated with an Improved Overall Survival for Patients with Primary Malignant Bone Tumors Who Have Metastatic Disease at Presentation? Clin Orthop Relat Res 2020; 478:2284-2295. [PMID: 32667758 PMCID: PMC7491913 DOI: 10.1097/corr.0000000000001361] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The management of primary malignant bone tumors in patients with metastatic disease at presentation remains a challenge. Although surgical resection has been a mainstay in the management of nonmetastatic malignant bone tumors, there is a lack of large-scale evidence-based guidance on whether surgery of the primary site/tumor improves overall survival in malignant bone tumors with metastatic disease at presentation. QUESTIONS/PURPOSES (1) Is surgical resection of the primary tumor associated with improved overall survival in patients with primary malignant bone tumors who have metastatic disease at presentation? (2) What other factors are associated with improved and/or poor overall survival? METHODS The 2004 to 2016 National Cancer Database (NCDB), a national registry containing data from more than 34 million cancer patients in the United States, was queried using International Classification of Diseases, 3rd Edition, topographical codes to identify patients with primary malignant bone tumors of the extremities (C40.0-C40.3, C40.8, and C40.9) and/or pelvis (C41.4). The NCDB was preferred over other national cancer registries (that is, the Surveillance, Epidemiology, and End Results database) because it includes a specific variable that codes for patients who received additional surgeries at metastatic sites. Patients with malignant bone tumors of the head or skull, trunk, and spinal column were excluded because these patients are not routinely encountered and treated by orthopaedic oncologists. Histologic codes were used to categorize the tumors into the following groups: osteosarcomas, chondrosarcomas, and Ewing sarcomas. Patients whose tumors were classified as Stage 1, 2, or 3 based on American Joint Commission of Cancer guidelines were excluded. Only patients who presented with metastatic disease were included in the final study sample. The study sample was divided into two distinct groups: those who underwent surgical resection of the primary tumor and those who did not receive any operation for the primary tumor. A total of 2288 patients with primary malignant bone tumors (1121 osteosarcomas, 345 chondrosarcomas, and 822 Ewing sarcomas) with metastatic disease at presentation were included, of whom 46% (1053 of 2288) underwent surgical resection of the primary site. Thirty-three percent (348 of 1053) of patients undergoing surgical resection of the primary site also underwent additional resection of metastases. Patients undergoing surgical resection of the primary site typically were younger than 18 years, lived further from a facility, had tumors involving the upper or lower extremity, had a diagnosis of osteosarcoma or chondrosarcoma, and had a greater tumor size and higher tumor grade at presentation. To account for baseline differences within the patient population and to adjust for additional confounding variables, multivariate Cox regression analyses were used to assess whether undergoing surgical resection of the primary tumor was associated with improved overall survival, after controlling for differences in baseline demographics, tumor characteristics (grade, location, histologic type, and tumor size), and treatment patterns (resection of distant or regional metastatic sites, positive or negative surgical margins, and use of radiation therapy or chemotherapy). Additional sensitivity analyses, stratified by histologic type for osteosarcomas, chondrosarcomas, and Ewing sarcomas, were used to assess factors associated with overall survival for each tumor type. RESULTS After controlling for differences in baseline demographics, tumor characteristics, and treatment patterns, we found that surgical resection of the primary site was associated with reduced overall mortality compared with those who did not have a resection of the primary site (hazard ratio 0.42 [95% confidence interval 0.36 to 0.49]; p < 0.001). Among other factors, in the stratified analysis, radiation therapy was associated with improved overall survival for patients with Ewing sarcoma (HR 0.71 [95% CI 0.57 to 0.88]; p = 0.002) but not for those with osteosarcoma (HR 1.14 [95% CI 0.91 to 1.43]; p = 0.643) or chondrosarcoma (HR 1.0 [95 % CI 0.78 to 1.50]; p = 0.643). Chemotherapy was associated with improved overall survival for those with osteosarcoma (HR 0.50 [95% CI 0.39 to 0.64]; p < 0.001) and those with chondrosarcoma (HR 0.62 [95% CI 0.45 to 0.85]; p = 0.003) but not those with Ewing sarcoma (HR 0.7 [95% CI 0.46 to 1.35]; p = 0.385). CONCLUSIONS Surgical resection of the primary site was associated with an overall survival advantage in patients with primary malignant bone tumors who presented with metastatic disease. Further research, using more detailed data on metastatic sites (such as, size, location, number, and treatment), chemotherapy regimen and location of radiation (primary or metastatic site) is warranted to better understand which patients will have improved overall survival and/or a benefit in the quality of life from resecting their primary malignant tumor if they present with metastatic disease at diagnosis. LEVEL OF EVIDENCE Level III, therapeutic study.
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27
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Panuganti BA, Stuart E, Weissbrod P. Changes in treatment trends in the early glottic cancer population after the Affordable Care Act. Head Neck 2020; 43:137-144. [PMID: 32945595 DOI: 10.1002/hed.26463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/18/2020] [Accepted: 08/26/2020] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The clinical impact of Medicaid expansion in otolaryngology is uncertain. Herein, we evaluate the impact of Medicaid expansion on treatment patterns (primary radiotherapy vs surgery) in the early glottic cancer population. METHODS Data regarding adults with Tis-T2N0M0 glottic cancer that were treated with either surgery or radiotherapy between January 2010 and December 2016 were obtained from the Surveillance, Epidemiology, and End Results (SEER) cancer database. Changes in treatment trends and survival in the Medicaid expansion setting were discerned. RESULTS The proportion of patients undergoing radiotherapy decreased from 64.8% to 59% after the Patient Protection and Affordable Care Act (PPACA) was implemented. State Medicaid expansion status was associated with reduced odds of radiation therapy (odds ratio [OR] = 0.66). Patients were diagnosed more often with earlier stage disease (20.6% vs 17.0% T2 diagnoses) in the Medicaid expansion cohort. CONCLUSION The implementation of the PPACA was associated with a significant increase in surgical therapy for and earlier diagnosis of glottic cancer.
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Affiliation(s)
- Bharat Akhanda Panuganti
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, University of California - San Diego, San Diego, California, USA
| | - Emelia Stuart
- Department of Otolaryngology-Head and Neck Surgery, University of California - Davis, Sacramento, California, USA
| | - Philip Weissbrod
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, University of California - San Diego, San Diego, California, USA
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28
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Berger MH, Yasaka TM, Haidar YM, Kuan EC, Tjoa T. Insurance Status as a Predictor of Treatment in Human Papillomavirus Positive Oropharyngeal Cancer. Laryngoscope 2020; 131:776-781. [PMID: 32790156 DOI: 10.1002/lary.28984] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/10/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVES The link between human papillomavirus (HPV) and oropharyngeal cancer (OPC) is well known. Locally advanced, HPV-positive OPC (HPV OPC) can be treated with either chemoradiation or primary surgery with or without adjuvant therapy. Head and neck cancer patients with government insurance or uninsured have been shown to have worse prognosis than similar patients with private insurance. In this study, we aimed to determine if insurance status would predict treatment modality in patients with HPV OPC. STUDY DESIGN A retrospective analysis using the National Cancer Database (NCDB). METHODS The National Cancer Database was used to identify patients with HPV OPC who underwent primary surgery or primary chemoradiation from 2010-2015. Insurance status was categorized as government, private, or no insurance. The relationship between insurance status and treatment was investigated using Chi square and multivariate regression models. Kaplan-Meier analyses were performed comparing overall survival (OS) by insurance status. RESULTS There were 10,606 patients were included. There was a statistically significant correlation between insurance status and primary treatment modality for HPV OPC (P < .001). Patients with government insurance were 19.3% less likely to undergo surgery and uninsured patients were 36.9% less likely to undergo primary surgery when compared to those with private insurance (P < .001), even after correcting for TNM stage in multivariate analysis. There was an improved 5-year OS for patients with private insurance (86.6%) versus both government insurance (68.4%) and no insurance (69.9%) (P < .001). CONCLUSIONS Patients with private insurance are more likely to undergo primary surgery in HPV OPC and have improved overall survival. LEVEL OF EVIDENCE 4 Laryngoscope, 131:776-781, 2021.
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Affiliation(s)
- Michael H Berger
- Department of Head and Neck Surgery, University of California Irvine, Irvine, California, U.S.A
| | - Tyler M Yasaka
- Department of Head and Neck Surgery, University of California Irvine, Irvine, California, U.S.A
| | - Yarah M Haidar
- Department of Head and Neck Surgery, University of California Irvine, Irvine, California, U.S.A
| | - Edward C Kuan
- Department of Head and Neck Surgery, University of California Irvine, Irvine, California, U.S.A
| | - Tjoson Tjoa
- Department of Head and Neck Surgery, University of California Irvine, Irvine, California, U.S.A
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29
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Moss HA, Wu J, Kaplan SJ, Zafar SY. The Affordable Care Act's Medicaid Expansion and Impact Along the Cancer-Care Continuum: A Systematic Review. J Natl Cancer Inst 2020; 112:779-791. [PMID: 32277814 PMCID: PMC7825479 DOI: 10.1093/jnci/djaa043] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/18/2020] [Accepted: 03/23/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Health reform and the merits of Medicaid expansion remain at the top of the legislative agenda, with growing evidence suggesting an impact on cancer care and outcomes. A systematic review was undertaken to assess the association between Medicaid expansion and the goals of the Patient Protection and Affordable Care Act in the context of cancer care. The purpose of this article is to summarize the currently published literature and to determine the effects of Medicaid expansion on outcomes during points along the cancer care continuum. METHODS A systematic search for relevant studies was performed in the PubMed/MEDLINE, EMBASE, Scopus, and Cochrane databases. Three independent observers used an abstraction form to code outcomes and perform a quality and risk of bias assessment using predefined criteria. RESULTS A total of 48 studies were identified. The most common outcomes assessed were the impact of Medicaid expansion on insurance coverage (23.4% of studies), followed by evaluation of racial and/or socioeconomic disparities (17.4%) and access to screening (14.5%). Medicaid expansion was associated with increases in coverage for cancer patients and survivors as well as reduced racial- and income-related disparities. CONCLUSIONS Medicaid expansion has led to improved access to insurance coverage among cancer patients and survivors, particularly among low-income and minority populations. This review highlights important gaps in the existing oncology literature, including a lack of studies evaluating changes in treatment and access to end-of-life care following implementation of expansion.
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Affiliation(s)
| | - Jenny Wu
- Duke University School of Medicine, Durham NC, USA
| | | | - S Yousuf Zafar
- Duke Cancer Institute, Duke-Margolis Center for Health Policy, Durham, NC, USA
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Wang K, Mao W, Shi H, Wang G, Yin L, Xie J, Ian LH, Zhang H, Peng B. Marital status impacts survival in patients with upper tract urothelial carcinoma: a population-based, propensity-matched study. Transl Androl Urol 2020; 9:1611-1629. [PMID: 32944523 PMCID: PMC7475671 DOI: 10.21037/tau-20-605] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Marital status has been considered as an independent prognostic factor for various types of cancer survival. The objectives of our study were to investigate the function of marital status on the survival of upper tract urothelial carcinoma (UTUC) patients. Methods The patients diagnosed with UTUC between 1988 and 2015 were captured within the Surveillance, Epidemiology, and End Results (SEER) database. Patients were classified into married, divorced/separated, widowed and single cohorts. Kaplan-Meier and Cox regression analysis was conducted to assess the effects of marital status on overall survival (OS) and cancer-specific survival (CSS). A 1:1 matched‐pair analysis was performed to optimize the final statistical results by propensity score matching (PSM). Results Among the 10,852 eligible patients, the percentage of married, divorced/separated, widowed and single patients accounted for 58.2% (6,321), 9.0% (980), 23.3% (2,526) and 9.4% (1,025) respectively. The widowed patients had the worst OS and CSS. Marital status was a predictive factor for OS and CSS of UTUC patients. The results of multivariate Cox regression showed that the worst OS [hazard ratio (HR): 1.41; 95% confidence interval (CI): 1.33–1.49, P<0.001] and the poorer CSS (HR: 1.32; 95% CI: 1.22–1.43, P<0.001) were existed in the widowed patients, compared with married patients. The results of the stratified analysis by primary site also indicated the same conclusion. Furthermore, the results were confirmed in the 1:1 matched group. Conclusions Marital status acted as an independent prognostic and protective factor for survival in UTUC patients. Additionally, being widowed was related with a high risk of death in UTUC compared with married, divorced, or single patients.
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Affiliation(s)
- Keyi Wang
- Department of Urology, People's Hospital of Putuo District, School of Medicine, Tongji University, Shanghai, China.,Department of Urology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Weipu Mao
- Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
| | - Heng Shi
- Department of Urology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Guangchun Wang
- Department of Urology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Lei Yin
- Department of Urology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jinbo Xie
- Department of Urology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Lap Hong Ian
- Department of Urology, Centro Hospitalar Conde de São Januário (CHCSJ) Hospital, Macau, China
| | - Hui Zhang
- Department of Anesthesiology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Bo Peng
- Department of Urology, People's Hospital of Putuo District, School of Medicine, Tongji University, Shanghai, China.,Department of Urology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
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Osazuwa-Peters N, Barnes JM, Megwalu U, Adjei Boakye E, Johnston KJ, Gaubatz ME, Johnson KJ, Panth N, Sethi RKV, Varvares MA. State Medicaid expansion status, insurance coverage and stage at diagnosis in head and neck cancer patients. Oral Oncol 2020; 110:104870. [PMID: 32629408 DOI: 10.1016/j.oraloncology.2020.104870] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 06/17/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Only one in three head and neck cancer (HNC) patients present with early-stage disease. We aimed to quantify associations between state Medicaid expansions and changes in insurance coverage rates and stage at diagnosis of HNC. METHODS Using a quasi-experimental difference-in-differences (DID) approach and data from 26,330 cases included in the Surveillance, Epidemiology, and End Results program (2011-2015), we retrospectively examined changes in insurance coverage and stage at diagnosis of adult HNC in states that expanded Medicaid (EXP) versus those that did not (NEXP). RESULTS There was a significant increase in Medicaid coverage in EXP (+1.6 percentage point (PP) versus) vs. NEXP (-1.8 PP) states (3.36 PP, 95% CI = 1.32, 5.41; p = 0.001), and this increase was mostly among residents of low income and education counties. We also observed a reduction in uninsured rates among HNC patients in low income counties (-4.17 PP, 95% CI = -6.84, -1.51; p = 0.002). Overall, early stage diagnosis rates were 28.3% (EXP) vs. 26.7% (NEXP), with significant increases in early stage diagnosis post-Medicaid expansion among young adults, 18-34 years (17.2 PP, 95% CI - 1.34 to 33.1, p = 0.034), females (7.54 PP, 95% CI = 2.00 to 13.10, p = 0.008), unmarried patients (3.83 PP, 95% CI = 0.30-7.35, p = 0.033), and patients with lip cancer (13.5 PP, 95% CI = 2.67-24.3, p = 0.015). CONCLUSIONS Medicaid expansion is associated with improved insurance coverage rates for HNC patients, particularly those with low income, and increases in early stage diagnoses for young adults and women.
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Affiliation(s)
- Nosayaba Osazuwa-Peters
- Saint Louis University Cancer Center, St. Louis, MO, USA; Saint Louis University School of Medicine, Department of Otolaryngology-Head and Neck Surgery, St. Louis, MO, USA.
| | - Justin M Barnes
- Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Uchechukwu Megwalu
- Stanford University School of Medicine, Department of Otolaryngology - Head and Neck Surgery, Stanford, CA, USA
| | - Eric Adjei Boakye
- Southern Illinois University School of Medicine, Department of Population Science and Policy, Springfield, IL, USA
| | - Kenton J Johnston
- Saint Louis University College for Public Health and Social Justice, Department of Health Management and Policy, St. Louis, MO, USA; Saint Louis University Center for Health Outcomes Research (SLUCOR), St. Louis, MO, USA
| | | | | | - Neelima Panth
- Yale School of Medicine, Department of Surgery, Division of Otolaryngology, New Haven, CT, USA
| | - Rosh K V Sethi
- University of Michigan Health System, Department of Otolaryngology Head and Neck Surgery, Ann Arbor, MI, USA
| | - Mark A Varvares
- Harvard Medical School, Massachusetts Eye and Ear Infirmary, Department of Otolaryngology, Boston, MA, USA
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Babu A, Wassef DW, Sangal NR, Goldrich D, Baredes S, Park RCW. The Affordable Care Act: Implications for underserved populations with head & neck cancer. Am J Otolaryngol 2020; 41:102464. [PMID: 32307190 DOI: 10.1016/j.amjoto.2020.102464] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 03/13/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE This study was done to determine the direct impact implementation of the Affordable Care Act (ACA) on patients with Head and Neck Cancer (HNCA) in states that chose to expand Medicaid compared to in states that did not, as well as assess whether this impact varied among different demographic groups. MATERIALS AND METHODS The Surveillance, Epidemiology, and End Results (SEER) database was queried for cases of HNCA diagnosed from 2011 to 2014. Rates of uninsured status were compared before and after Medicaid expansion and contrasted between states that did and did not expand coverage, stratified by patient and tumor characteristics, and assessed via multivariate regression. RESULTS Overall rates of uninsured status (UR) were decreased by 63.08% in states that expanded coverage (ES) but only by 2.6% in states that did not (NS). In NS, there was an increase in proportion of black patients who were uninsured over the study period (13.7%, p = 0.077) whereas in ES, this proportion decreased by 73.3%. When stratified by primary site, patients with laryngeal cancer had the highest UR with an increase by 16.7% in NS and a decrease by 70.5% in ES. Multivariate analysis yielded predictors of uninsured status including residence in a NS, Hispanic ethnicity, and black race. CONCLUSIONS Implementation of the ACA resulted in expanded insurance coverage for patients diagnosed with HNCA concentrated mainly in states that expanded Medicaid coverage and for patients derived from vulnerable populations, including black and Hispanic patients. In states that did not expand Medicaid, vulnerable populations were disproportionately affected.
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Panth N, Barnes JM, Simpson MC, Adjei Boakye E, Sethi RKV, Varvares MA, Osazuwa-Peters N. Change in stage of presentation of head and neck cancer in the United States before and after the affordable care act. Cancer Epidemiol 2020; 67:101763. [PMID: 32593161 DOI: 10.1016/j.canep.2020.101763] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 06/01/2020] [Accepted: 06/03/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE/HYPOTHESIS Early diagnosis and stage at presentation, two prognostic factors for survival among patients with head and neck cancer (HNC), are significantly impacted by a patient's health insurance status. We aimed to assess the impact of the Patient Protection and Affordable Care Act (ACA) on stage at presentation across socioeconomic and demographic subpopulations of HNC patients in the United States. STUDY DESIGN Retrospective data analysis. METHODS The National Cancer Database, a hospital-based cancer database (2011-2015), was queried for adults aged 18-64 years and diagnosed with a malignant primary HNC. The outcome of interest was change in early-stage diagnoses between 2011-2013 (pre-ACA) and 2014-2015 (post-ACA) using logistic regression models. RESULTS A total of 91,137 HNC cases were identified in the pre-ACA (n = 53,726) and post-ACA (n = 37,411) years. Overall, the odds of early-stage diagnoses did not change significantly post-ACA (aOR = 0.97, 95 % CI 0.94, 1.00; p = 0.081). However, based on health insurance status, HNC patients with Medicaid were significantly more likely to present with early-stage disease post-ACA (aOR = 1.12, 95 % CI 1.03, 1.21; p = 0.007). We did not observe increased odds of early-stage presentation for other insurance types. Males were less likely to present with early-stage disease, pre- or post-ACA. CONCLUSIONS We demonstrate a significant association between ACA implementation and increased early-stage presentation among Medicaid-enrolled HNC patients. This suggests that coverage expansions through the ACA may be associated with increased access to care and may yield greater benefits among low-income HNC patients.
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Affiliation(s)
- Neelima Panth
- Yale School of Medicine, Department of Surgery, Division of Otolaryngology, New Haven, CT, USA
| | - Justin M Barnes
- Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Matthew C Simpson
- Saint Louis University School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Saint Louis, MO, USA; Saint Louis University Cancer Center, Saint Louis, MO, USA
| | - Eric Adjei Boakye
- Southern Illinois University School of Medicine, Department of Population Science and Policy, Springfield, IL, USA
| | - Rosh K V Sethi
- University of Michigan Health System, Department of Otolaryngology Head and Neck Surgery, Ann Arbor, MI, USA
| | - Mark A Varvares
- Harvard Medical School, Massachusetts Eye and Ear Infirmary, Department of Otolaryngology, Boston, MA, USA
| | - Nosayaba Osazuwa-Peters
- Saint Louis University School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Saint Louis, MO, USA; Saint Louis University Cancer Center, Saint Louis, MO, USA.
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Graboyes E, Cramer J, Balakrishnan K, Cognetti DM, López-Cevallos D, de Almeida JR, Megwalu UC, Moore CE, Nathan CA, Spector ME, Lewis CM, Brenner MJ. COVID-19 pandemic and health care disparities in head and neck cancer: Scanning the horizon. Head Neck 2020; 42:1555-1559. [PMID: 32562325 PMCID: PMC7323088 DOI: 10.1002/hed.26345] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/04/2020] [Indexed: 12/30/2022] Open
Abstract
The COVID-19 pandemic has profoundly disrupted head and neck cancer (HNC) care delivery in ways that will likely persist long term. As we scan the horizon, this crisis has the potential to amplify preexisting racial/ethnic disparities for patients with HNC. Potential drivers of disparate HNC survival resulting from the pandemic include (a) differential access to telemedicine, timely diagnosis, and treatment; (b) implicit bias in initiatives to triage, prioritize, and schedule HNC-directed therapy; and (c) the marked changes in employment, health insurance, and dependent care. We present four strategies to mitigate these disparities: (a) collect detailed data on access to care by race/ethnicity, income, education, and community; (b) raise awareness of HNC disparities; (c) engage stakeholders in developing culturally appropriate solutions; and (d) ensure that surgical prioritization protocols minimize risk of racial/ethnic bias. Collectively, these measures address social determinants of health and the moral imperative to provide equitable, high-quality HNC care.
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Affiliation(s)
- Evan Graboyes
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - John Cramer
- Department of Otolaryngology-Head & Neck Surgery, Wayne State University, Detroit, Michigan, USA
| | - Karthik Balakrishnan
- Department of Otolaryngology-Head & Neck Surgery, Stanford University, Stanford, California, USA
| | - David M Cognetti
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Daniel López-Cevallos
- School of Language, Culture & Society, Oregon State University, Corvallis, Oregon, USA
| | - John R de Almeida
- University Health Network/ Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, USA
| | - Uchechukwu C Megwalu
- Department of Otolaryngology-Head & Neck Surgery, Stanford University, Stanford, California, USA
| | - Charles E Moore
- Department of Otolaryngology-Head & Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - Cherie-Ann Nathan
- Department of Otolaryngology-Head & Neck Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Matthew E Spector
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Carol M Lewis
- Head & Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael J Brenner
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Segel JE, Jung J. Coverage, Financial Burden, and the Patient Protection and Affordable Care Act for Patients With Cancer. J Oncol Pract 2019; 15:e1035-e1049. [DOI: 10.1200/jop.19.00138] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: Evidence suggests coverage has improved significantly for patients with cancer, particularly in the lower-income population, after the implementation of the Affordable Care Act (ACA). Yet no study has examined changes in type of coverage or the resulting effect on spending and financial burden. METHODS: Using 2011 to 2015 Medical Expenditure Panel Survey data, we examine changes in type of coverage, spending, and financial burden among lower-income (< 400% of federal poverty level [FPL]) individuals diagnosed with cancer after the ACA. To better understand the changes, we compare this sample to the lower-income patients without cancer and patients with cancer with a higher income (≥ 400% of FPL). All analyses were conducted in 2018. RESULTS: In adjusted analyses, we found a decline in months uninsured (−0.78 months; P = .001) and an increase in months with Medicaid coverage (0.40 months; P = .059) among the lower-income patients with cancer. This change is similar to the lower-income patients without cancer. We found an increase in total expenditures ($3,020; P = .071) but a modest decline in the fraction of family income spent on health (−0.014; P = 0.099), although neither is statistically significant. For the higher income patients with cancer, we observed significant increases in both out-of-pocket premiums and medical financial burden. CONCLUSION: After the ACA, lower-income people diagnosed with cancer experienced significant gains in coverage largely through Medicaid at rates similar to lower-income patients without cancer, but patients with cancer with incomes 400% or greater of FPL faced a higher financial burden.
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Affiliation(s)
- Joel E. Segel
- Pennsylvania State University, University Park, Pennsylvania
- Penn State Cancer Institute, Hershey, Pennsylvania
| | - Jeah Jung
- Pennsylvania State University, University Park, Pennsylvania
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Sanford NN, Lam MB, Butler SS, Ahn C, Beg MS, Aizer AA, Mahal BA. Self-reported Reasons and Patterns of Noninsurance Among Cancer Survivors Before and After Implementation of the Affordable Care Act, 2000-2017. JAMA Oncol 2019; 5:e191973. [PMID: 31091534 DOI: 10.1001/jamaoncol.2019.1973] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Cancer survivors experience difficulties in maintaining health care coverage, but the reasons and risk factors for lack of insurance are poorly defined. Objective To assess self-reported reasons for not having insurance and demographic and socioeconomic factors associated with uninsured status among cancer survivors, before and after implementation of the Affordable Care Act (ACA) in 2014. Design, Setting, and Participants This survey study analyzes National Health Interview Survey (NHIS) data from January 1, 2000, through December 31, 2017. Included were adult participants (age, 18-64 years) reporting a cancer diagnosis; however, those with a diagnosis of nonmelanoma skin cancer were excluded. Exposures Insurance status. Main Outcomes and Measures Multivariable logistic regression was used to define the association between demographic and socioeconomic variables and odds of being uninsured. The prevalence of the most common self-reported reasons for not having insurance (cost, unemployment, employment-related reason, family-related reason) were estimated, with adjusted odds ratios (aORs) for each of the reasons defined by multivariable logistic regression. Results Among 17 806 survey participants, the mean (SD) age was 50.9 (10.8) years, and 6121 (34.4%) were men. A total of 1842 participants (10.3%) reported not having health insurance. Individuals surveyed in 2000 to 2013 had higher odds of not having insurance than those surveyed in 2014 to 2017 (10.6% vs 6.2%; aOR 1.75; 95% CI 1.49-2.08). Variables associated with higher odds of uninsured status included younger age (14.2% for age younger than mean vs 6.5% for age older than mean; aOR, 1.84; 95%, CI, 1.62-2.10), annual family income below the poverty threshold (21.4% vs 8.0%; aOR, 1.97; 95%, CI, 1.69-2.30), Hispanic ethnicity (18.8% vs 9.0%; aOR, 1.87; 95% CI, 1.51-2.33), noncitizen status (24.3% vs 9.2%; aOR, 2.38; 95% CI, 1.69-3.34), and current smoking (18.6% vs. 6.7%; aOR, 2.65; 95% CI, 2.32-3.02). Before the ACA, increasing interval from cancer diagnosis was associated with not having insurance (12.3% for ≥6 years vs 8.9% for 0-5 years; aOR, 1.47; 95% CI 1.26-1.70) as was black race (13.9% for black patients vs 10.4% for nonblack patients; AOR, 1.29; 95% CI, 1.04-1.61), but after the ACA, they no longer were (6.8% for ≥6 years vs 5.6% for 0-5 years; aOR, 1.12; 95% CI, 0.82-1.54; and 6.9% for black patients vs 6.2% for nonblack patients; aOR, 0.81; 95% CI, 0.46-1.43). The most commonly cited reason for not having insurance was cost, followed by unemployment, both of which decreased after ACA implementation (cost, 49.6% vs 37.6%, aOR [pre-ACA vs post-ACA], 0.62; 95% CI, 0.46-0.85; unemployment, 37.1% vs 28.5%; aOR 0.62; 95% CI, 0.45-0.87). Conclusions and Relevance The proportion of uninsured cancer survivors decreased after implementation of the ACA, but certain subgroups remained at greater risk of being uninsured. Cost was identified as the primary barrier to obtaining insurance, although more than half of cancer survivors reported other barriers to coverage.
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Affiliation(s)
- Nina N Sanford
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas
| | - Miranda B Lam
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, Massachusetts.,Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Santino S Butler
- Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Chul Ahn
- Division of Biostatistics, Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
| | - Muhammad S Beg
- Department of Medical Oncology, University of Texas Southwestern Medical Center, Dallas
| | - Ayal A Aizer
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, Massachusetts.,Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Brandon A Mahal
- Dana-Farber Cancer Institute McGraw/Patterson Center for Population Sciences, Boston, Massachusetts
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