Relationship between insurance status and outcomes for patients with breast cancer in Missouri

Sociodemographic Disparities in Rectal Cancer Outcomes within Academic Cancer Centers

BACKGROUND

Sociodemographic disparities in cancer care outcomes are often related to delayed or limited care access. However, it is unknown whether outcome differences persist after establishing high-level care. This study evaluated the relationship between rectal cancer outcomes and sociodemographic status at academic cancer centers.

PATIENTS AND METHODS

A retrospective cohort study of patients with rectal cancer treated at academic cancer centers was conducted utilizing the National Cancer Database. Primary outcome was overall survival, while secondary outcomes included 30- and 90-day mortality, time from diagnosis to treatments, hospital readmission rates, and hospital length of stay.

RESULTS

Of the 127,023 patients, median age was 62.7 years (SD 11.92), 59.3% were male, 80.3% were white, and 39.4% presented with stage III disease. After adjustment, Black patients had the worst overall survival (HR 1.10, 95% CI 1.01-1.19, p = 0.016). Private insurance status conferred overall survival benefit (HR 0.66, 95% CI 0.58-0.75, p < 0.001) as well as the best protection against 30- and 90- day postoperative mortality (30-day OR 0.31, 95% CI 0.10-0.97, p = 0.044; 90-day OR 0.37, 95% CI 0.16-0.83, p = 0.015). Black patients experienced longer time to first treatment than their white counterparts, with a delay of 3.23 days (95% CI 1.87-4.58, p < 0.001).

CONCLUSIONS

This study demonstrated the existence of sociodemographic disparities even within the walls of academic institutions, where care should be evidence-based, standardized, comprehensive, and equitable. When analyzing causal pathways, delays in time to treatment initiation may be contributing to these outcomes, but may be modifiable.

Factors associated with locoregional recurrence after neoadjuvant chemotherapy for breast cancer in a safety-net medical center

BACKGROUND

The management of locally advanced breast cancer poses significant challenges, with contemporary strategies involving an approach that combines systemic and local treatment. The current study was performed to validate the clinical impression that locoregional recurrences have become increasingly uncommon after standardized multimodal treatment protocol.Please check and confirm that the authors and their respective affiliations have been correctly identified and amend if necessary.All authors and affiliations are correct.

METHODS

A retrospective analysis was performed using a single-institution database that included clinical, radiographic, and pathologic parameters for all non-metastatic and non-inflammatory breast cancer patients treated with neoadjuvant chemotherapy (NAC) from 2015 to 2023. Uni- and multivariable analyses were performed to define associations between clinical factors, recurrence, and RFS.

RESULTS

The median age was 51 years for 274 predominantly Hispanic (78%) patients, with a median follow-up of 38.1 months. The recurrence rates were 4% local, 2% regional, and 18% distant. Median time from surgery to local recurrence was 8.2 months and to regional recurrence was 9.7 months. There were no locoregional clinical recurrences in 92 (34%) patients who had pCR or in 85 (31%) patients who had radiological complete response after NAC. Locoregional recurrences were uncommon > 12 months after surgery. Five of 11 local recurrences occurred in patients who had a poor response to NAC (ypT4b). All 6 patients having regional recurrences had adjuvant radiation therapy, and only 2 occurred in patients who were pathologically node-negative (ypN0) post-NAC.

CONCLUSIONS

Favorable responses to NAC were associated with excellent locoregional control rates. Results achieved for predominantly Hispanic patients at a safety net medical center were similar to those reported in prospective, randomized clinical trials.

Impact of Racial Disparities on Treatment of Early Triple Negative Breast Cancer Among American Indians/Alaska Natives and Non-Hispanic Whites

BACKGROUND

Differences in patient and tumor characteristics among American Indian/Alaska Native (AI/AN) and non-Hispanic White (NHW) breast cancers (BC) adversely impact overall survival (OS) in AI/AN. The aims of this study were to: 1) investigate disparities in treatment of early triple negative breast cancers (TNBC); 2) assess differences in OS.

METHODS

A hospital-based, retrospective cohort study using the National Cancer Database included AI/AN and NHW women, 18 years or older, diagnosed with TNBC between 2010 and 2019, stages I-III. Propensity score matching (1:3 ratio) was used for age, year, and analytic stage at diagnosis.

RESULTS

A total of 489 AI/AN and 1465 available matched NHW women with TNBC were analyzed. Time to first treatment (TFT) was significantly longer for AI/AN (P = .005). Multivariate analysis revealed that longer TFT was associated with only higher Charlson-Deyo Score (CDS) (P = .014) and nonprivate insurance (P < .001), but not race (P = .568). Overall treatment compliance was similar (AI/AN - 89.6% vs. NHW - 92.2%, P = .074). Compliance was significantly associated with only insurance status (P < .001). On multivariate analysis OS did not differ by race (P = .687, HR = 1.06; 95% CI: 0.79-1.44). Cancer stage, CDS, insurance status, and treatment compliance were associated with worse OS.

CONCLUSION

In patients with TNBC, there was no difference in TFT, compliance with recommended treatment or OS among AI/AN in comparison to White women when matched for age, stage, and year of diagnosis. In order to improve BC survival, it is important to manage comorbid conditions and improve detection of cancer at earlier stages.

An innovative approach to the multidisciplinary treatment of uninsured breast cancer patients

PURPOSE

A significant proportion of many populations remain uninsured. The aim of the study was to assess differences in breast cancer outcomes before and after the implementation of an innovative approach to the multidisciplinary treatment of uninsured breast cancer patients.

METHODS

Retrospective review was performed of patients seen at a safety net hospital from January 2000 to December 2020. Beginning July 2006, an innovative approach was implemented to lower patient costs and facilitate care of uninsured patients.

RESULTS

The study included 1,797 patients, 661 patients before the changes (BCS), and 1136 patients after implementation of the new cost saving approach (ACS). The mean age was 53 years. The majority were uninsured (56%) or insured by Medicaid (31%). Only 18% underwent screening mammography. The ACS group had a higher rate of breast conservation (75% vs 47%, p < 0.001). A higher percentage of the ACS group received adjuvant therapy: Chemotherapy (91% vs 70%, p < 0.001), Radiation therapy (91% vs 70%, p < 0.001), and initiated endocrine therapy (87% vs 67%, p < 0.001). After follow-up of 8 years, these changes resulted in lower ipsilateral breast tumor recurrence (2% vs 16%, p < 0.001) and chest wall recurrence (5% versus 8%) and improvement in overall survival (90% vs 81%, p < 0.001).

CONCLUSION

Peer-reviewed literature is replete of studies documenting disparities in breast cancer treatment. The current study describes a successful cost-limiting method which takes advantage of existing financial assistance programs to improve care in uninsured patients.

Racial differences in carcinoma-in-situ and non-muscle-invasive bladder cancer mortality: Accounting for insurance status, black segregation, and neighborhood poverty

BACKGROUND

Few Bladder Cancer (BC) studies have examined the role of area-level variables. The purpose of this study was to examine racial differences in BC survival to elucidate if insurance status and contextual covariates could explain Black disadvantage in survival.

METHOD

Using the Fine-Gray subdistribution hazard models (sHR), five-year survival time was calculated from the date of diagnosis until the last day of follow-up or the date of death due to BC in Florida 2000-2014 (n = 32,321). Non-BC deaths were considered a competing risk. In all models, individual-level clinical and demographic variables were adjusted for and we included the exposures of interest for Carcinoma-in-Situ (CIS) and Non-Muscle-Invasive BC(NMIBC), separately.

RESULTS

In CIS-Patients, living in neighborhoods with higher levels of segregation was associated with 50 % to 2-fold increase in sHR (medium level segregation sHR= 1.50, 95 % CI: 1.06-2.13; high level segregation sHR= 2.07, 95 % CI: 1.25-3.43). Uninsured CIS patients had more than 2-fold increased sHR compared to those with private insurance (sHR=2.34, 95 % CI: 1.05-5.24). In NMIBC patients, living in areas with level of poverty resulted in 10 % the hazard of death increased when compared to low poverty (high poverty sHR=1.11, 95 % CI: 1.01-1.21). Uninsured and Medicaid covered NMIBC patients had an increased sHR (uninsured sHR=2.05, 95 % CI: 1.62-2.59; Medicaid sHR=1.36, 95 % CI: 1.11-1.67). For both CIS and NMIBC patients, the Black/White survival gap decreased when insurance and contextual variables were included.

CONCLUSION

This study identified BC survival rates were different for Black and White patients in Florida and found that those observed gaps were, to some extent, linked to broader social factors. We recommend that future cancer studies examining racial disparities incorporate area-level variables to offer a more nuanced understanding of these complex disparities.

Breast Radiation Therapy Survivorship and Cancer Support Groups: an Opportunity for Community Engagement and Education Through the Addressing Breast Cancer Dermatologic Side Effects (ABCDEs) Program

Breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer deaths in women in the USA. To serve under-insured breast cancer patients in South Texas, we designed a patient education program to improve health literacy of secondary dermatologic changes after completing radiation therapy. A needs assessment survey was distributed to better understand the patients' stage of treatment, experiences with radiation-induced dermatologic side effects, and over-the-counter skin products and home remedies used. Of the 33 patients that participated in this program, nearly all patients (93.94%, n = 31) are either currently undergoing treatment or have completed treatment. Of the 31 individuals, 74.19% of patients (n = 23) have completed treatment at least 9-12 months ago, 22.58% (n = 7) are currently receiving chemotherapy, and 3.23% (n = 1) are currently undergoing radiation therapy. Among the dermatologic side effects, patients experienced changes to skin color, redness, and burns/burning sensation at the greatest severity. The top products used by survey participants were prescription-strength topical corticosteroids (65.63%) followed by oral analgesics (28.13%) and compression sleeves (25.00%). Aloe vera (15.63%) was the most used complementary and alternative therapeutic treatment. By surveying experiences of radiation-induced dermatologic side effects in predominantly under-resourced and minority communities, we can better tailor patient education programs to reflect patients' experiences. Overall, this program can enhance clinicians' insight on under-resourced patient experiences to improve health literacy and dispel common misconceptions surrounding breast cancer treatment, management, and survivorship.

Breast cancer treatment delay and the Hispanic paradox: A SEER database analysis

BACKGROUND

Breast cancer (BC) is the most common cancer in US women. Knowledge gaps exist regarding healthcare inequities in Hispanic BC patients. This study assessed BC characteristics and treatment patterns among Hispanics.

METHODS

Hispanic and non-Hispanic white women (NHW) with invasive BC from the SEER Database (2018-2020) were included. We evaluated if Hispanic ethnicity was associated with time from diagnosis to treatment (TT) and its impact on cancer-specific survival. Treatment delay was defined as > 3 months post-diagnosis. Logistic regression, Kaplan-Meier curves, and Cox regression models were used.

RESULTS

Among 135,690 patients, 16.5 ​% were Hispanic. Median TT for Hispanics was 1.5 ​÷ ​1.34 months vs. 1.22 ​÷ ​1.07 months for NHW (p ​< ​0.001). Adjusted analysis showed Hispanics had 2.47 times higher odds of delayed TT than NHW (95 ​% CI: 2.29-2.66). Delayed TT worsened survival in both groups; however, within the delayed TT, Hispanics had better survival (HR: 0.52, 95 ​% Cl: 0.27-0.98, p ​= ​0.045).

CONCLUSIONS

Disparities in healthcare for Hispanic patients exist; targeted interventions and public health initiatives are needed to ensure equitable care.

Impact of Structural Racism and Social Determinants of Health on Disparities in Breast Cancer Mortality

The striking ethnic and racial disparities in breast cancer mortality are not explained fully by pathologic or clinical features. Structural racism contributes to adverse conditions that promote cancer inequities, but the pathways by which this occurs are not fully understood. Social determinants of health, such as economic status and access to care, account for a portion of this variability, yet interventions designed to mitigate these barriers have not consistently led to improved outcomes. Based on the current evidence from multiple disciplines, we describe a conceptual model in which structural racism and racial discrimination contribute to increased mortality risk in diverse groups of patients by promoting adverse social determinants of health that elevate exposure to environmental hazards and stress; these exposures in turn contribute to epigenetic and immune dysregulation, thereby altering breast cancer outcomes. Based on this model, opportunities and challenges arise for interventions to reduce racial and ethnic disparities in breast cancer mortality.

Patient-reported observations on medical procedure timeliness (PROMPT) in breast cancer: a qualitative study

PURPOSE

Timeliness of care is an important healthcare outcome measure. The objective of this study was to explore patient perspectives on the timeliness of breast cancer diagnosis and treatment at accredited breast cancer centers.

METHODS

In this qualitative study, 1 hour virtual interviews were conducted with participants 18-75 years old who were diagnosed and treated for stage 0-III breast cancer at a National Accreditation Program for Breast Centers facility from 2018 to 2022. Thematic analysis was used to identify key themes of participant experiences.

RESULTS

Twenty-eight participants were interviewed. Two thematic domains were identified: etiologies of expedited or delayed care and the impact of delayed or expedited care on patients. Within these domains, multiple themes emerged. For etiologies of expedited or delayed care, participants discussed (1) the effect of scheduling appointments, (2) the COVID-19 pandemic, (3) dissatisfaction with the timeline for various parts of the diagnostic workup, and (4) delays related to patient factors, including socioeconomic status. For the impact of expedited or delayed care, patients discussed (1) the emotional and mental impact of waiting, (2) the importance of communication and clear expectations, and (3) the impact of electronic health portals. Patients desired each care interval (e.g., the time from mammogram to breast biopsy) to be approximately 7 days, with longer intervals sometimes preferred prior to surgery.

CONCLUSION

These patient interviews identify areas of delay and provide patient-centered, actionable items to improve the timeliness of breast cancer care.

Medicare billing and utilization trends in vascular surgery

OBJECTIVE

Within the past decade, Medicare Part B reimbursements for various surgical procedures have been declining, whereas health care expenses continue to increase. As a result, hospitals may increase service charges to offset losses in revenue, which may disproportionately affect underinsured patients. Our analysis aimed to characterize Medicare billing and utilization trends across common vascular surgical procedures.

METHODS

The 2017 to 2021 Medicare Physician and Other Practitioners by Provider and Service dataset was queried for Current Procedural Terminology (CPT) codes for common vascular surgery procedures. The average charges, reimbursements, charge-to-reimbursement ratios, and service counts were calculated for the most common interventions performed by vascular surgeons. Data was stratified by care setting, facility (inpatient and outpatient hospital) vs non-facility locations. All monetary values were adjusted to the 2021 United States dollars to account for inflation.

RESULTS

For facility settings, the mean charge billed to Medicare Part B increased from $3708 to $3952 (6.6%) from 2017 to 2021, with the average charge-to-reimbursement ratio increasing from 7.2 to 8.6. There were 17 of the 19 facility procedures that had a decline in reimbursements, decreasing from an average of $558 to $499 (-10.4%). Stab phlebectomy had the largest individual decrease in facility reimbursement (-53.5%), followed by above-knee amputation (-11.3%) and below-knee amputation (-11.0%). Both non-facility charges (-10.8%) and reimbursements (-12.2%) declined over the study period. Procedural utilization remained stable from 2017 to 2019. Tibial and femoral-popliteal atherectomy had increases of 45.9% and 33.7%, respectively, in overall procedural utilization when performed in non-facility settings from 2017 to 2019.

CONCLUSIONS

Our analysis of vascular surgery procedures billed to Medicare Part B from 2017 to 2021 demonstrates an increase in charges, a decline in reimbursements, and a resultant increase in charge-to-reimbursement ratios for facility care settings. In contrast, non-facility charges have decreased in the face of declining reimbursements. These markups in submitted charges in facility locations may serve as an additional barrier to accessing care for patients who are underinsured.

Trends in Hospital Billing for Mastectomy and Breast Reconstruction Procedures from 2013 to 2020

BACKGROUND

 With greater acceptance of postmastectomy breast reconstruction (PMBR) as a safe and reliable treatment option, the role of plastic surgeons in breast cancer management continues to rise. As Medicare reimbursements for surgical procedures decline, hospitals may increase charges. Excessive markups can negatively affect uninsured and underinsured patients. We aimed to analyze mastectomy and breast reconstruction procedures to gain insights into recent trends in utilization and billing.

METHODS

 We queried the 2013 to 2020 Medicare Provider Utilization and Payment Data with 14 Current Procedural Terminology (CPT) codes to collect service count numbers, hospital charges, and reimbursements. We calculated utilization (service counts per million female Medicare enrollees), weighted mean charges and reimbursements, and charge-to-reimbursement ratios (CRRs). We calculated total and annual percentage changes for the included CPT codes.

RESULTS

 Among the 14 CPT codes, 12 CPT codes (85.7%) with nonzero service counts were included. Utilization of mastectomy and breast reconstruction procedures decreased from 1,889 to 1,288 (-31.8%) procedures per million female Medicare beneficiaries from 2013 to 2020. While the utilization of immediate implant placements (CPT 19340) increased by 36.2%, the utilization of delayed implant placements (CPT 19342) decreased by 15.1%. Reimbursements for the included CPT codes changed minimally over time (-2.9%) but charges increased by 28.9%. These changes resulted in CRRs increasing from 3.3 to 4.4 (+33.3%) from 2013 to 2020. Free flap reconstructions (CPT 19364) had the highest CRRs throughout the study period, increasing from 7.0 in 2013 to 10.3 in 2020 (+47.1%).

CONCLUSIONS

 Our analysis of mastectomy and breast reconstruction procedures billed to Medicare Part B from 2013 to 2020 showed increasingly excessive procedural charges. Rises in hospital charges and CRRs may limit uninsured and underinsured patients from accessing necessary care for breast cancer management. Legislations that monitor hospital markups for PMBR procedures may be considered by policymakers.

Impact of patient, hospital, and operative characteristics relative to social determinants of health: Compliance with National Comprehensive Cancer Network guidelines for colon cancer

BACKGROUND

Despite an established association with improved patient outcomes, compliance with National Comprehensive Cancer Network (NCCN) guidelines remains suboptimal. We sought to assess the effect of patient characteristics (PCs), operative characteristics (OCs), hospital characteristics (HCs), and social determinants of health (SDoH) on noncompliance with NCCN guidelines for colon cancer.

METHODS

Patients treated for stage I to III colon cancer from 2004 to 2017 were identified from the National Cancer Database. Multilevel multivariate regression analysis was performed to identify factors associated with receipt of NCCN-compliant care and quantify the proportion of variance explained by PCs, OCs, HCs, and SDoH.

RESULTS

Among 468,097 patients with colon cancer treated across 1319 hospitals, 1 in 4 patients did not receive NCCN-compliant care (122,170 [26.1%]). On regression analysis, older age (odds ratio [OR], 0.96; 95% CI, 0.96-0.96), female sex (OR, 0.97; 95% CI, 0.96-0.99), Black race (OR, 0.96; 95% CI, 0.94-0.98), higher Charlson-Deyo score (OR, 0.84; 95% CI, 0.82-0.86), tumor stage ≥II (OR, 0.42; 95% CI, 0.40-0.44), and tumor grade ≥ 3 (OR, 0.33; 95% CI, 0.32-0.34) were associated with lower odds of receiving NCCN-compliant care (all P values <.05). Higher hospital volume (OR, 1.02; 95% CI, 1.02-1.03), minimally invasive or robotic surgical approach (OR, 1.26; 95% CI, 1.23-1.29), adequate (≥12) lymph node assessment (OR, 3.46; 95% CI, 3.38-3.53), private insurance status (OR, 1.33; 95% CI, 1.26-1.40), Medicare insurance status (OR, 1.42; 95% CI, 1.35-1.49), and higher educational status (OR, 1.06; 95% CI, 1.02-1.09) were associated with higher odds of receiving NCCN-compliant care (all P values <.05). Overall, PCs contributed 36.5%, HCs contributed 1.3%, and OCs contributed 12.9% to the variation in guideline-compliant care, while SDoH contributed only 3.6% of the variation in receipt of NCCN-compliant care.

CONCLUSION

The variation in NCCN-compliant care among patients with colon cancer was largely attributable to patient- and surgeon-level factors, whereas SDoH were associated with a smaller proportion of the variation.

Demographic differences in early vs. late-stage laryngeal squamous cell carcinoma

PURPOSE

This study aims to evaluate how various demographic factors impact the stage at diagnosis and, therefore, prognosis of laryngeal cancer.

MATERIALS AND METHODS

Using the National Cancer Database, 96,409 patients were diagnosed with laryngeal squamous cell carcinoma between 2004 and 2020. Early (stage 0 or I) vs. late-stage (stage IV) cancers were compared based on demographic variables utilizing Chi-square and multivariate analysis with a significance of p < 0.05.

RESULTS

Female, Black, and generally older patients were more likely to have late-stage cancer than their counterparts. When compared with a community cancer program, patients treated at other facility types were more likely to be diagnosed late. Patients with private insurance, Medicare, or other government insurance were all less likely to have late-stage cancer compared to patients without insurance. Compared to patients in the lowest median household income quartile, patients in the third quartile and fourth quartile were diagnosed earlier. Patients living in an area with the lowest level of high school degree attainment were most likely to be diagnosed late. Living in a more populous area was associated with a lower chance of being diagnosed late. Increasing Charlson-Deyo Score was associated with a stronger likelihood of being diagnosed at a later stage.

CONCLUSION

Patients who are female, Black, uninsured, have a low household income, live in less populated and less educated areas, are treated at non-community cancer programs, and have more comorbid conditions have later stage diagnoses. This data contributes to understanding inequities in healthcare.

Billing and Utilization Trends in Reconstructive Microsurgery Indicate Worsening Access to Care

BACKGROUND

 Within the last 20-years, Medicare reimbursements for microsurgery have been declining, while physician expenses continue to increase. As a result, hospitals may increase charges to offset revenue losses, which may impose a financial barrier to care. This study aimed to characterize the billing trends in microsurgery and their implications on patient care.

METHODS

 The 2013 to 2020 Provider Utilization and Payment Data Physician and Other Practitioners Dataset was queried for 16 CPT codes. Service counts, hospital charges, and reimbursements were collected. The utilization, weighted mean reimbursements and charges, and charge-to-reimbursement ratios (CRRs) were calculated. The total and annual percent changes were also determined.

RESULTS

 In total, 13 CPT codes (81.3%) were included. The overall number of procedures decreased by 15.0%. The average reimbursement of all microsurgical procedures increased from $618 to $722 (16.7%). The mean charge increased from $3,200 to $4,340 (35.6%). As charges had a greater increase than reimbursement rates, the CRR increased by 15.4%. At the categorical level, all groups had increases in CRRs, except for bone graft (-49.4%) and other procedures (-3.5%). The CRR for free flap breast procedures had the largest percent increase (47.1%). Additionally, lymphangiotomy (28.6%) had the second largest increases.

CONCLUSION

 Our analysis of microsurgical procedures billed to Medicare Part B from 2013 to 2020 showed that hospital charges are increasing at a faster rate than reimbursements. This may be in part due to increasing physician expenses, cost of advanced technology in microsurgical procedures, and inadequate reimbursement rates. Regardless, these increased markups may limit patients who are economically disadvantaged from accessing care. Policy makers should consider legislation aimed at updating Medicare reimbursement rates to reflect the increasing complexity and cost associated with microsurgical procedures, as well as regulating charge markups at the hospital level.

Effect of Medicaid expansion on cancer treatment and survival among Medicaid beneficiaries and the uninsured

BACKGROUND

The Affordable Care Act expanded Medicaid coverage for people with low income in the United States. Expanded insurance coverage could promote more timely access to cancer treatment, which could improve overall survival (OS), yet the long-term effects of Medicaid expansion (ME) remain unknown. We evaluated whether ME was associated with improved timely treatment initiation (TTI) and 3-year OS among patients with breast, cervical, colon, and lung cancers who were affected by the policy.

METHODS

Medicaid-insured or uninsured patients aged 40-64 with stage I-III breast, cervical, colon, or non-small cell lung cancer within the National Cancer Database (NCDB). A difference-in-differences (DID) approach was used to compare changes in TTI (within 60 days) and 3-year OS between patients in ME states versus nonexpansion (NE) states before (2010-2013) and after (2015-2018) ME. Adjusted DID estimates for TTI and 3-year OS were calculated using multivariable linear regression and Cox proportional hazards regression models, respectively.

RESULTS

ME was associated with a relative increase in TTI within 60 days for breast (DID = 4.6; p < 0.001), cervical (DID = 5.0 p = 0.013), and colon (DID = 4.0, p = 0.008), but not lung cancer (p = 0.505). In Cox regression analysis, ME was associated with improved 3-year OS for breast (DID hazard ratio [HR] = 0.82, p = 0.009), cervical (DID-HR = 0.81, p = 0.048), and lung (DID-HR = 0.87, p = 0.003). Changes in 3-year OS for colon cancer were not statistically different between ME and NE states (DID-HR, 0.77; p = 0.075).

CONCLUSIONS

Findings suggest that expanded insurance coverage can improve treatment and survival outcomes among low income and uninsured patients with cancer. As the debate surrounding ME continues nationwide, our findings serve as valuable insights to inform the development of policies aimed at fostering accessible and affordable healthcare for all.

Preexisting Diabetes and Breast Cancer Treatment Among Low-Income Women

IMPORTANCE

Diabetes is associated with poorer prognosis of patients with breast cancer. The association between diabetes and adjuvant therapies for breast cancer remains uncertain.

OBJECTIVE

To comprehensively examine the associations of preexisting diabetes with radiotherapy, chemotherapy, and endocrine therapy in low-income women with breast cancer.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study included women younger than 65 years diagnosed with nonmetastatic breast cancer from 2007 through 2015, followed up through 2016, continuously enrolled in Medicaid, and identified from the linked Missouri Cancer Registry and Medicaid claims data set. Data were analyzed from January 2022 to October 2023.

EXPOSURE

Preexisting diabetes.

MAIN OUTCOMES AND MEASURES

Logistic regression was used to estimate odds ratios (ORs) of utilization (yes/no), timely initiation (≤90 days postsurgery), and completion of radiotherapy and chemotherapy, as well as adherence (medication possession ratio ≥80%) and persistence (<90-consecutive day gap) of endocrine therapy in the first year of treatment for women with diabetes compared with women without diabetes. Analyses were adjusted for sociodemographic and tumor factors.

RESULTS

Among 3704 women undergoing definitive surgery, the mean (SD) age was 51.4 (8.6) years, 1038 (28.1%) were non-Hispanic Black, 2598 (70.1%) were non-Hispanic White, 765 (20.7%) had a diabetes history, 2369 (64.0%) received radiotherapy, 2237 (60.4%) had chemotherapy, and 2505 (67.6%) took endocrine therapy. Compared with women without diabetes, women with diabetes were less likely to utilize radiotherapy (OR, 0.67; 95% CI, 0.53-0.86), receive chemotherapy (OR, 0.67; 95% CI, 0.48-0.93), complete chemotherapy (OR, 0.71; 95% CI, 0.50-0.99), and be adherent to endocrine therapy (OR, 0.71; 95% CI, 0.56-0.91). There were no significant associations of diabetes with utilization (OR, 0.95; 95% CI, 0.71-1.28) and persistence (OR, 1.09; 95% CI, 0.88-1.36) of endocrine therapy, timely initiation of radiotherapy (OR, 1.09; 95% CI, 0.86-1.38) and chemotherapy (OR, 1.09; 95% CI, 0.77-1.55), or completion of radiotherapy (OR, 1.25; 95% CI, 0.91-1.71).

CONCLUSIONS AND RELEVANCE

In this cohort study, preexisting diabetes was associated with subpar adjuvant therapies for breast cancer among low-income women. Improving diabetes management during cancer treatment is particularly important for low-income women with breast cancer who may have been disproportionately affected by diabetes and are likely to experience disparities in cancer treatment and outcomes.

Social Determinants of Health Framework to Identify and Reduce Barriers to Imaging in Marginalized Communities

Social determinants of health (SDOH) are conditions influencing individuals' health based on their environment of birth, living, working, and aging. Addressing SDOH is crucial for promoting health equity and reducing health outcome disparities. For conditions such as stroke and cancer screening where imaging is central to diagnosis and management, access to high-quality medical imaging is necessary. This article applies a previously described structural framework characterizing the impact of SDOH on patients who require imaging for their clinical indications. SDOH factors can be broadly categorized into five sectors: economic stability, education access and quality, neighborhood and built environment, social and community context, and health care access and quality. As patients navigate the health care system, they experience barriers at each step, which are significantly influenced by SDOH factors. Marginalized communities are prone to disparities due to the inability to complete the required diagnostic or screening imaging work-up. This article highlights SDOH that disproportionately affect marginalized communities, using stroke and cancer as examples of disease processes where imaging is needed for care. Potential strategies to mitigate these disparities include dedicating resources for clinical care coordinators, transportation, language assistance, and financial hardship subsidies. Last, various national and international health initiatives are tackling SDOH and fostering health equity.

Are There More HER2 FISH in the Sea? An Institution's Experience in Identifying HER2 Positivity Using Fluorescent In Situ Hybridization in Patients with HER2 Negative Immunohistochemistry

BACKGROUND

Approximately 20% of breast cancers express HER2-positive receptors in the USA. HER2 receptor immunohistochemistry (IHC) staining with equivocal (2+) results commonly undergoes fluorescence in-situ hybridization (FISH) for further classification. Current guidelines do not recommend routine FISH testing in IHC-negative (0 or 1+) cases. This study investigates an institution that performs both IHC and FISH testing on all cases to identify the true HER2-positive rate.

PATIENTS AND METHODS

A retrospective chart review from 2015 to 2021 was conducted at an institution where both HER2 IHC and FISH testing were performed at the time of diagnosis for all invasive breast cancers. The rate of true HER2-positive patients was determined, and patient and tumor characteristics were further explored.

RESULTS

A total of 1835 invasive breast cancer cases were primarily treated at this institution. A total of 289 cases were HER2 positive on IHC and FISH testing (15.7%). An additional 38 cases were identified as HER2 negative on IHC, but reclassified as HER2 positive on reflex FISH testing. Total HER2 positive cases increased from 289 (15.7%) to 327 cases (17.8%) with reflex FISH testing.

CONCLUSIONS

The additional HER2-positive cases after completing FISH testing on IHC-negative tumors suggests there may be a role for routine FISH testing in addition to standard IHC staining to determine HER2 status for breast cancer. The ethical, prognostic and even  benefits of a correct diagnosis outweigh the added expense of FISH testing.

The Impact of Health Inequities on Population-Based Breast Cancer Survival in a Colombian Population, 2008-2015

OBJECTIVE

To obtain breast cancer survival estimates in Manizales, Colombia, considering socioeconomic level, health insurance regime and residential area, while adjusting for age, histology and stage at diagnosis.

METHODS

Analytical cohort study based on breast cancer incident cases recorded by the Population-based Manizales Cancer Registry between 2008-2015. Patients were followed-up for 60 months. Cause-specific survival was calculated using the Kaplan-Meier method for variables of interest, with the Wilcoxon-Breslow-Gehan test for differences. Cox multivariate regression models were fitted.

RESULTS

856 breast cancer cases were included. The 5-year cause-specific survival for the entire cohort was 78.2%. It was higher in women with special/exception health insurance, high socioeconomic level, <50 years old, ductal carcinoma, and stages I and II. Residential area did not impact survival. In Cox models, the subsidized health insurance regime (HR: 4.87 vs contributory) and low socioeconomic level (HR: 2.45 vs high) were predictors of the hazard of death in women with breast cancer, adjusted for age, histology, stage and interactions age-stage and insurance-stage. A positive interaction (synergistic effect modification) between health insurance regime and stage regarding to survival was observed.

CONCLUSION

Socioeconomic factors significantly contribute to the inequities in breast cancer survival, independent of the stage at diagnosis. This suggests the need for comprehensive interventions to remove barriers to accessing the health system. This research provides evidence of survival gaps mediated by certain social determinants of health and generates data on the overall performance of the Colombian health system.

Comparison of primary payer in cancer registry and discharge data

OBJECTIVES

To determine agreement between variables capturing the primary payer at cancer diagnosis across the Pennsylvania Cancer Registry (PCR) and statewide facility discharge records (Pennsylvania Health Care Cost Containment Council [PHC4]) for adults younger than 65 years, and to specifically examine factors associated with misclassification of Medicaid status in the registry given the role of managed care.

STUDY DESIGN

Cross-sectional analysis of the primary cancer cases among adults aged 21 to 64 years in the PCR from 2010 to 2016 linked to the PHC4 facility visit records.

METHODS

We assessed agreement of payer at diagnosis (Medicare, Medicaid, private, other, uninsured, unknown) across data sources, including positive predictive value (PPV) and sensitivity, using the PHC4 records as the gold standard. The probability of misclassifying Medicaid in registry was estimated using multivariate logit models.

RESULTS

Agreement of payers was high for private insurance (PPV, 89.7%; sensitivity, 83.6%), but there was misclassification and/or underreporting of Medicaid in the registry (PPV, 80%; sensitivity, 58%). Among cases with "other" and "unknown" insurance, 73.8% and 62.1%, respectively, had private insurance according to the PHC4 records. Medicaid managed care was associated with a statistically significant increase of 12.6 percentage points (95% CI, 9.4-15.8) in the probability of misclassifying Medicaid enrollment as private insurance in the registry.

CONCLUSIONS

Findings suggest caution in conducting and interpreting research using insurance variables in cancer registries.

Associations between health insurance status, neighborhood deprivation, and treatment delays in women with breast cancer living in Georgia

BACKGROUND

Little is known regarding the association between insurance status and treatment delays in women with breast cancer and whether this association varies by neighborhood socioeconomic deprivation status.

METHODS

In this cohort study, we used medical record data of women diagnosed with breast cancer between 2004 and 2022 at two Georgia-based healthcare systems. Treatment delay was defined as >90 days to surgery or >120 days to systemic treatment. Insurance coverage was categorized as private, Medicaid, Medicare, other public, or uninsured. Area deprivation index (ADI) was used as a proxy for neighborhood-level socioeconomic status. Associations between delayed treatment and insurance status were analyzed using logistic regression, with an interaction term assessing effect modification by ADI.

RESULTS

Of the 14,195 women with breast cancer, 54% were non-Hispanic Black and 52% were privately insured. Compared with privately insured patients, those who were uninsured, Medicaid enrollees, and Medicare enrollees had 79%, 75%, and 27% higher odds of delayed treatment, respectively (odds ratio [OR]: 1.79, 95% confidence interval [CI]: 1.32-2.43; OR: 1.75, 95% CI: 1.43-2.13; OR: 1.27, 95% CI: 1.06-1.51). Among patients living in low-deprivation areas, those who were uninsured, Medicaid enrollees, and Medicare enrollees had 100%, 84%, and 26% higher odds of delayed treatment than privately insured patients (OR: 2.00, 95% CI: 1.44-2.78; OR: 1.84, 95% CI: 1.48-2.30; OR: 1.26, 95% CI: 1.05-1.53). No differences in the odds of delayed treatment by insurance status were observed in patients living in high-deprivation areas.

DISCUSSION/CONCLUSION

Insurance status was associated with treatment delays for women living in low-deprivation neighborhoods. However, for women living in neighborhoods with high deprivation, treatment delays were observed regardless of insurance status.

Disentangling Social Determinants of Health and Rurality in Head and Neck Cancer 2-Year Mortality

Social determinants of health (SDoH) and rurality are known factors that may influence outcomes in head and neck squamous cell carcinoma (HNSCC). Patients residing in remote locations or those with multiple SDoH may encounter barriers to initial diagnosis, adherence to multidisciplinary treatments, and posttreatment surveillance, which may impact their overall survival. However, previous studies have shown mixed results associated with rural residence. The aim of this study is to identify the impact of rurality and SDoH on 2-year survival in HNSCC. The study was conducted using a Head and Neck Cancer Registry at a single institution from June 2018 through July 2022. Rurality, defined by US census scores, and individual measures of SDoH were used. Our results indicate that each additional adverse SDoH factor results in 1.5 times the odds of mortality at 2 years. Individualized measures of SDoH, rather than rurality alone, better reflect patient prognosis in HNSCC.

Cancer Disparities among Pacific Islanders: A Review of Sociocultural Determinants of Health in the Micronesian Region

It is well appreciated that the social determinants of health are intimately related with health outcomes. However, there is a paucity of literature that explores these themes comprehensively for the indigenous people within Micronesia. Certain Micronesia-specific factors, such as transitions from traditional diets, the consumption of betel nut, and exposure to radiation from the nuclear bomb testing in the Marshall Islands, have predisposed certain Micronesian populations to an increased risk of developing a variety of malignancies. Furthermore, severe weather events and rising sea levels attributed to climate change threaten to compromise cancer care resources and displace entire Micronesian populations. The consequences of these risks are expected to increase the strain on the already challenged, disjointed, and burdened healthcare infrastructure in Micronesia, likely leading to more expenses in off-island referrals. A general shortage of Pacific Islander physicians within the workforce reduces the number of patients that can be seen, as well as the quality of culturally competent care that is delivered. In this narrative review, we comprehensively underscore the health disparities and cancer inequities faced by the underserved communities within Micronesia.

Disparities in hepatocellular carcinoma survival by Medicaid-status: A national population-based risk analysis

BACKGROUND

Previous studies have demonstrated disparities in survival surrounding hepatocellular carcinoma (HCC) across a variety of socio-demographic factors; however, the relationship between Medicaid-status and HCC survival is poorly understood.

METHODS

We constructed 5-year, disease-specific survival curves using the Kaplan-Meier method and performed an adjusted survival analysis using multivariate Cox-proportional hazard regression.

RESULTS

We analyzed 17,059 non-elderly patients (12,194 non-Medicaid, 4875 Medicaid) diagnosed between 2006 and 2013 and found that Medicaid status was not associated with higher risk of diseases-specific death compared to other insurance types (p = .232, aHR 1.02, 95% CI: 0.983-1.07) after for controlling for a variety of co-variates (ie. marital status, urbanicity, etc.). We found no difference in the risk of death between patients enrolled in Medicaid for more than three years versus those enrolled for less than three years. In all models, rurality and unmarried status were also associated with an increased risk of death (aHR 1.11, 95% CI: 1.03-1.18, p = .002 and aHR 1.18, 95% CI: 1.13-1.23, p < .001, respectively).

DISCUSSION

Those enrolled in Medicaid prior to HCC diagnosis may not be associated with a higher risk of disease-specific death compared to non-Medicaid enrolled patients.

Does Age Younger Than 65 Affect Clinical Outcomes in Medicare Patients Undergoing Lumbar Fusion?

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

To determine if age (younger than 65) and Medicare status affect patient outcomes following lumbar fusion.

SUMMARY OF BACKGROUND DATA

Medicare is a common spine surgery insurance provider, but most qualifying patients are older than age 65. There is a paucity of literature investigating clinical outcomes for Medicare patients under the age of 65.

MATERIALS AND METHODS

Patients 40 years and older who underwent lumbar fusion surgery between 2014 and 2019 were queried from electronic medical records. Patients with >2 levels fused, >3 levels decompressed, incomplete patient-reported outcome measures (PROMs), revision procedures, and tumor/infection diagnosis were excluded. Patients were placed into 4 groups based on Medicare status and age: no Medicare under 65 years (NM<65), no Medicare 65 years or older (NM≥65), yes Medicare under 65 (YM<65), and yes Medicare 65 years or older (YM≥65). T tests and χ 2 tests analyzed univariate comparisons depending on continuous or categorical type. Multivariate regression for ∆PROMs controlled for confounders. Alpha was set at 0.05.

RESULTS

Of the 1097 patients, 567 were NM<65 (51.7%), 133 were NM≥65 (12.1%), 42 were YM<65 (3.8%), and 355 were YM≥65 (32.4%). The YM<65 group had significantly worse preoperative Visual Analog Scale back ( P =0.01) and preoperative and postoperative Oswestry Disability Index (ODI), Short-Form 12 Mental Component Score (MCS-12), and Physical Component Score (PCS-12). However, on regression analysis, there were no significant differences in ∆PROMs for YM <65 compared with YM≥65, and NM<65. NM<65 (compared with YM<65) was an independent predictor of decreased improvement in ∆ODI following surgery (β=12.61, P =0.007); however, overall the ODI was still lower in the NM<65 compared with the YM<65.

CONCLUSION

Medicare patients younger than 65 years undergoing lumbar fusion had significantly worse preoperative and postoperative PROMs. The perioperative improvement in outcomes was similar between groups with the exception of ∆ODI, which demonstrated greater improvement in Medicare patients younger than 65 compared with non-Medicare patients younger than 65.

LEVEL OF EVIDENCE

Level III (treatment).

Does Age and Medicare Status Affect Clinical Outcomes in Patients Undergoing Anterior Cervical Discectomy and Fusion?

OBJECTIVE

The objective of this study was to determine if Medicare status and age affect clinical outcomes following anterior cervical discectomy and fusion.

METHODS

Patients who underwent cervical discectomy and fusion between 2014 and 2020 with complete preoperative and 1-year postoperative patient-reported outcome measures (PROMs) were grouped based on Medicare status and age: no Medicare under 65 years (NM < 65), Medicare under 65 years (M < 65), no Medicare 65 years or older (NM ≥ 65), and Medicare 65 years or older (M ≥ 65). Multivariate regression for ΔPROMs (Δ: postoperative minus preoperative) controlled for confounding differences between groups. Significant was set at P < 0.05.

RESULTS

A total of 1288 patients were included, with each group improving in the visual analog score (VAS) Neck (all, P < 0.001), VAS Arm (M < 65: P = 0.003; remaining groups: P < 0.001), and Neck Disability Index (M < 65: P = 0.009; remaining groups: P < 0.001) following surgery. Only M < 65 did not significantly improve in the Physical Component Score (PCS-12) and modified Japanese Orthopaedic Association (mJOA) score (P = 0.256 and P = 0.092, respectively). When comparing patients under 65 years, non-Medicare patients had better preoperative PCS-12 (P < 0.001), Neck Disability Index (P < 0.001), and modified Japanese Orthopaedic Association (P < 0.001), as well as better postoperative values for all PROMs (P < 0.001), but there were no differences in ΔPROMs. Multivariate analysis identified M < 65 to be an independent predictor of decreased improvement in ΔPCS-12 (β = -4.07, P = 0.015), ΔVAS Neck (β = 1.17, P = 0.010), and ΔVAS Arm (β = 1.15, P = 0.025) compared to NM < 65.

CONCLUSIONS

Regardless of age and Medicare status, all patients undergoing cervical discectomy and fusion had significant clinical improvement postoperatively. However, Medicare patients under age 65 have a smaller magnitude of improvement in PROMs.

Sociodemographic Factors and Health Insurance Coverage Are Associated with Invasive Breast Cancer in Tennessee: Appalachian and Non-Appalachian County Comparison

Background:

Tennessean women experience the 12th highest breast cancer (BC) mortality in the United States. Yet, few studies have examined BC outcomes among Tennessean women in and outside of Appalachia. We examined whether sociodemographic factors and health insurance status were associated with invasive BC in Tennessee by Appalachian and non-Appalachian county designation.

Materials and Methods:

Using the Tennessee Cancer Registry, we identified 52,187 women, aged ≥18, diagnosed with BC between 2005 and 2015. Multivariable logistic regression was performed to examine associations between invasive BC and sociodemographic characteristics, health insurance coverage, and county designation (Appalachian/non-Appalachian). Regression analyses stratified by county designation were subsequently performed.

Results:

In Tennessee, younger women had lower odds of invasive BC diagnosis (<45: odds ratio [OR] = 0.74, 95% confidence interval [CI] = 0.67–0.81; 55–64: OR = 0.91, 95% CI = 0.84–0.97) compared to women ≥65. Married Tennessean women had 12% (95% CI = 1.04–1.21) higher odds of invasive BC than single women. Further, both public (OR = 1.81, 95% CI = 1.41–2.33) and private (OR = 1.36, 95% CI = 1.06–1.76) health insurance were found to increase odds of invasive BC compared to no insurance/self-pay. Results from the subpopulation analyses were largely consistent with overall findings. In Appalachian counties, women on public health insurance had increased odds (OR = 1.42, 95% CI = 1.00–2.03) of invasive BC compared to uninsured/self-pay women, while in non-Appalachian counties, women insured both publicly (OR = 2.25, 95% CI = 1.57–3.24) and privately (OR = 1.68, 95% CI = 1.16–2.24) had increased odds of invasive BC.

Conclusions:

The results identify risk factors for Tennessean women in Appalachian and non-Appalachian counties whose malignancies evaded early detection, increasing risk of mortality.

The Role of Safety-Net Hospitals in Reducing Disparities in Breast Cancer Care

Advances in breast cancer screening and systemic therapies have been credited with profound improvements in breast cancer outcomes; indeed, 5-year relative survival rate approaches 91% in the USA (U.S. National Institutes of Health NCI. SEER Training Modules, Breast). While breast cancer mortality has been declining, oncologic outcomes have not improved equally among all races and ethnicities. Many factors have been implicated in breast cancer disparities; chief among them is limited access to care which contributes to lower rates of timely screening mammography and, once diagnosed with breast cancer, lower rates of receipt of guideline concordant care (Wu, Lund, Kimmick GG et al. in J Clin Oncol 30(2):142-150, 2012). Hospitals with a safety-net mission, such as the essential hospitals, historically have been dedicated to providing high-quality care to all populations and have eagerly embraced the role of caring for the most vulnerable and working to eliminate health disparities. In this article, we review landmark articles that have evaluated the role safety-net hospitals have played in providing equitable breast cancer care including to those patients who face significant social and economic challenges.

OUP accepted manuscript

Background

Disrupted and delayed Medicaid coverage has been consistently associated with lower rates of cancer screening and early-stage cancer diagnosis compared with continuous coverage. However, the relationships between Medicaid coverage timing, breast cancer treatment delays, and survival are less clear.

Methods

Using the linked Missouri Cancer Registry-Medicaid claims data, we identified 4583 women diagnosed with breast cancer between 2007 and 2016. We used logistic regression to estimate odds ratios (ORs) of late-stage diagnosis and treatment delays for prediagnosis (>30 days, >90 days, and >1 year before diagnosis) vs peridiagnosis enrollment. Cox proportional hazards models were used to estimate the hazard ratio (HR) of breast cancer-specific mortality for pre- vs postdiagnosis enrollment.

Results

Patients enrolled in Medicaid more than 30 days before diagnosis were less likely to be diagnosed at a late stage compared with those enrolled in Medicaid peridiagnosis (OR = 0.69, 95% confidence interval [CI] = 0.60 to 0.79). This result persisted using enrollment 90-day (OR = 0.64, 95% CI = 0.56 to 0.74) and 1-year thresholds (OR = 0.55, 95% CI = 0.47 to 0.65). We did not observe a difference in the likelihood of treatment delays between the 2 groups. After adjustment for sociodemographic factors, there was no statistically significant difference in the risk of breast cancer mortality for patients enrolled more than 30 days prediagnosis relative to patients enrolled peridiagnosis (HR = 0.98, 95% CI = 0.83 to 1.14), but a lower risk was observed for patients enrolled prediagnosis when using 90 days (HR = 0.85, 95% CI = 0.72 to 0.999) or 1 year (HR = 0.79, 95% CI = 0.66 to 0.96) as the threshold.

Conclusions

Women with breast cancer who enroll in Medicaid earlier may benefit from earlier diagnoses, but only longer-term enrollment may have survival benefits.

Phenotype Discovery and Geographic Disparities of Late-Stage Breast Cancer Diagnosis across U.S. Counties: A Machine Learning Approach

BACKGROUND

Disparities in the stage at diagnosis for breast cancer have been independently associated with various contextual characteristics. Understanding which combinations of these characteristics indicate highest risk, and where they are located, is critical to targeting interventions and improving outcomes for patients with breast cancer.

METHODS

The study included women diagnosed with invasive breast cancer between 2009 and 2018 from 680 U.S. counties participating in the Surveillance, Epidemiology, and End Results program. We used a machine learning approach called Classification and Regression Tree (CART) to identify county "phenotypes," combinations of characteristics that predict the percentage of patients with breast cancer presenting with late-stage disease. We then mapped the phenotypes and compared their geographic distributions. These findings were further validated using an alternate machine learning approach called random forest.

RESULTS

We discovered seven phenotypes of late-stage breast cancer. Common to most phenotypes associated with high risk of late-stage diagnosis were high uninsured rate, low mammography use, high area deprivation, rurality, and high poverty. Geographically, these phenotypes were most prevalent in southern and western states, while phenotypes associated with lower percentages of late-stage diagnosis were most prevalent in the northeastern states and select metropolitan areas.

CONCLUSIONS

The use of machine learning methods of CART and random forest together with geographic methods offers a promising avenue for future disparities research.

IMPACT

Local interventions to reduce late-stage breast cancer diagnosis, such as community education and outreach programs, can use machine learning and geographic modeling approaches to tailor strategies for early detection and resource allocation.