Association of Medicaid Expansion with Racial Disparities in Cancer Stage at Presentation

Medicaid Expansion is Associated with Differences in Local Therapy for Non-small Cell Lung Cancer

BACKGROUND

Medicaid expansion under the Affordable Care Act aimed to expand healthcare access, improve quality, and reduce costs. The effects of Medicaid expansion on receipt of local therapy for lung cancer are unknown.

METHODS

We utilized the National Cancer Database to conduct a retrospective analysis of patients with clinical T1-2, N0, M0 non-small cell lung cancer (NSCLC) without neoadjuvant treatment. Patients living in Medicaid expansion states as of January 2014 were compared with patients in non-expansion states between 2010 and 2013 (pre-expansion) and 2016 and 2019 (post-expansion). A difference-in-difference (DID) analysis was used to compare rates of surgery and stereotactic body radiation therapy (SBRT).

RESULTS

Among 149,966 patients, there were 80,514 patients (53.6%) in Medicaid non-expansion states and 69,452 patients (46.3%) in expansion states. Receipt of local therapy (surgery or SBRT) {- 1.6% vs. - 2.8%, DID 1.24% [confidence interval (CI) 0.45-2.02%]} and receipt of surgery (- 7.9% vs. - 9.3%, DID 1.4% [0.46-2.4%]) decreased at a lesser rate in expansion states between 2010-2013 and 2016-2019. Among patients with Medicaid, receipt of local therapy (surgery or SBRT) and surgery increased at a greater rate in expansion states with a stronger treatment effect (18.9% vs. 1.1%, DID 7.8% [76.12-9.4%]; 8.1 vs. 0.12%, DID 8.0% [6.3-9.66%]). Patients who traveled >10 miles decreased at a greater rate in expansion states (3.7% vs. 5.1%, DID - 1.5% [- 2.46 to - 0.35%]).

CONCLUSION

Based on Medicaid expansion status, states have different changes in local therapy rates for NSCLC. Our data suggest that Medicaid expansion may increase healthcare access in the receipt of first-line treatment for early-stage NSCLC.

Impact of the Affordable Care Act and Medicaid Expansion Among Patients With HIV-Associated Aggressive B-Cell Non-Hodgkin Lymphomas

PURPOSE

To study the influence of the Affordable Care Act (ACA) policy and its Medicaid expansion on insurance status and survival in patients with HIV with aggressive lymphoma.

METHODS

We used the National Cancer Database, a hospital-based national registry, to identify adults age 18-64 years with HIV-associated aggressive B-cell non-Hodgkin lymphomas (HIV-a-B-NHLs), diagnosed during 2007 to 2016. Survival analysis was performed on a subset of patients with HIV-a-B-NHL for whom location data were available who resided in Medicaid expansion-adopted and nonadopted states. Using a quasi-experimental difference-in-difference model, the difference in adjusted 2-year survival rates obtained with a flexible parametric Weibull model was compared for states that adopted the Medicaid expansion of ACA against those that did not adopt the expansion.

RESULTS

We identified 8,231 patients with HIV-a-B-NHL and 50,650 non-HIV patients with a-B-NHL. We found that a lower proportion of individuals were uninsured at diagnosis in the expansion states compared with nonexpansion states. We also found that the ACA policy adoption led to a reduction in the proportion of uninsured individuals with HIV-a-B-NHL in expansion states of 34.9%, compared with 15.9% in non-expansion-adopted states. There was a statistically significant improvement in the 2-year survival rate among patients with HIV-a-B-NHL in the expansion compared with nonexpansion states with the adoption of ACA (7.17% v 1.58%, P = .02).

CONCLUSION

Using a novel quasi-experimental model, we found that the ACA policy corresponded with a greater survival improvement in patients with HIV-a-B-NHL within Medicaid expansion-adopted states compared with nonexpansion states. We believe that this evidence should be taken into consideration in future policy making.

Impact of Medicaid expansion on racial disparities among patients with gastrointestinal cancer

BACKGROUND

Racial minority groups experience disparities in cancer treatment and mortality. This study aimed to investigate the effect of Medicaid expansion on the existing racial disparities in all-cause mortality among patients with gastrointestinal malignancies.

METHODS

A cross-sectional cohort study of patients with pancreatic ductal adenocarcinoma (PDAC), colorectal cancer (CRC), and gastric adenocarcinoma (GC) of any stage was conducted using data from the National Cancer Database (2009-2019). Using difference-in-difference (DID) analysis, the authors compared adjusted 2-year mortality rates among Black and White patients residing in states with expanded Medicaid benefits (MES) and non-MES before (2009-2013) and after (2014-2019) Medicaid expansion.

RESULTS

A total of 86,052 patients were included in this analysis, including 19,188 patients with PDAC, 60,404 with CRC, and 6460 with GC. Two-year mortality rates decreased among Black patients with PDAC residing in MES but not those residing in non-MES following Medicaid expansion (DID, -9.4%; 95% confidence interval [CI], -14.4% to -4.4%; p < .001). Mortality decreased more among Black and White patients with CRC in MES compared to those in non-MES following Medicaid expansion (DID, -2.9%; 95% CI, -5.7 to -0.04; p = .047 and DID, -4.2%; 95% CI, -5.8 to -2.5; p < .001, respectively). Black patients with GC in MES experienced a marked reduction in mortality compared to those in non-MES (DID, -7.7%, 95% CI, -16.1 to 0.56; p = .07).

CONCLUSION

Medicaid expansion was associated with a greater reduction in 2-year mortality rates among Black patients residing in MES compared to those residing in non-MES. Existing racial disparities in mortality remained the same or worsened in non-MES but were mitigated in MES following Medicaid expansion in almost all comparisons.

Racioethnic disparities in comorbidities and outcomes following head and neck oncologic surgery

Objectives

Racial disparities persist despite attempts to establish an egalitarian framework for surgical care. This study aimed to investigate racioethnic disparities in comorbidities and outcomes following surgery for head and neck tumors.

Methods

This retrospective study included adult patients who underwent head and neck oncologic surgery between 2008 and 2020 from the National Surgical Quality Improvement Program. Multivariable regression analyses were conducted to explore the association of the following racioethnic categories with postoperative outcomes: White, Black, Hispanic, and Asian.

Results

A total of 113,234 patients were included in the study, comprising 78.3% White, 8.7% Black, 6.9% Hispanic, and 6.0% Asian patients. Black patients had higher rates of pre-existing comorbidities compared to White patients. Specifically, the rates of comorbidities such as diabetes mellitus (19.8% vs. 12.4%), hypertension (57.5% vs. 41.5%), smoking history (18.8% vs. 15.0%), dyspnea (7.4% vs. 5.7%), and preoperative anemia (43.6% vs. 36.5%) were higher among Black patients. On regression analyses, Black race was not associated with major morbidity following head and neck oncologic surgeries (odds ratio, 1.098, 95% confidence interval, 0.935-1.289) when compared to White patients. However, there were significant associations between the comorbidities associated with the Black race and an increased risk of major morbidity.

Conclusions

Black patients undergoing head and neck oncologic surgery face a significant challenge due to a higher burden of comorbidities. These comorbidities, in turn, have been found to be associated with postoperative major morbidity.

Association Between Medicaid Expansion and Insurance Status, Risk Group, Receipt, and Refusal of Treatment Among Men with Prostate Cancer

Background: Although the Patient Protection and Affordable Care Act (ACA) has been associated with increased Medicaid coverage among prostate cancer patients, the association between Medicaid expansion with risk group at diagnosis, time to treatment initiation (TTI), and the refusal of locoregional treatment (LT) among patients requires further exploration. Methods: Using the National Cancer Database, we performed a retrospective cohort analysis of all patients aged 40 to 64 years diagnosed with localized prostate cancer from 2011 to 2016. Difference-in-difference (DID) analysis was used to compare changes in insurance status, risk group at diagnosis, TTI, and the refusal of LT among patients residing in Medicaid expansion versus non-expansion states. In a secondary analysis, we used DID to compare changes in the above outcomes among racial minorities versus White patients living in expansion states. Results: Of the 112,434 patients with prostate cancer in our analysis, 50,958 patients lived in Medicaid expansion states, and 61,476 patients lived in non-expansion states. In the adjusted analysis, we found that the proportion of uninsured patients (adjusted DID: -0.87%; 95% confidence interval [95% CI]: -1.28 to -0.46) and patients who refused radiation therapy (adjusted DID: -0.71%; 95% CI: -0.95 to -0.47) decreased more in expansion states compared to non-expansion states. Similarly, we observed that the racial disparity of select outcomes in expansion states narrowed, as racial minorities experienced larger absolute decreases in uninsured status and the refusal of radiation therapy (RT) regimens than White patients following ACA implementation (p < 0.01 for all). However, residence in a Medicaid expansion state was not associated with changes in risk group at diagnosis, TTI, nor the refusal of LT (p > 0.01 for all); racial disparities in TTI were also exacerbated in expansion states following ACA implementation. Conclusions: The association between Medicaid expansion and prostate cancer outcomes and disparities remains unclear. While ACA implementation was associated with increased insurance coverage and decreased refusal of RT, there was no significant association with earlier risk group at diagnosis, TTI within 180 days, or refusal of LT. Similarly, racial minorities in expansion states had larger decreases in uninsured status and the refusal of RT regimens, as well as smaller increases in intermediate-/high-risk disease at presentation than White patients following ACA implementation, but experienced no significant changes in TTI. More research is needed to understand how Medicaid expansion affects cancer outcomes and whether these effects are borne equitably among different populations.

The Impact of Medicaid Expansion on Stage at Diagnosis of Melanoma Patients: A Retrospective Study

BACKGROUND

This study addresses the lack of research on Medicaid expansion's impact on melanoma staging, treatment utilization, and outcomes by evaluating its effects under the Affordable Care Act (ACA), particularly focusing on staging at diagnosis, treatment use, and 3-year mortality outcomes. The objective is to determine whether Medicaid expansion led to earlier melanoma diagnosis and improved survival rates among non-elderly adults (ages 40-64) by analyzing data from the National Cancer Database (NCDB).

METHODS

A total of 12,667 patients, aged 40-64, diagnosed with melanoma from 2010 to 2020 were identified using the NCDB. Difference-in-difference (DID) analysis was performed to analyze tumor staging at presentation between Medicaid expansion states and non-Medicaid expansion states both prior to the expansion and after the expansion.

RESULTS

Of the total patients, 2307 were from the pre-expansion time period residing in Medicaid expansion states (MES) and 1804 in non-Medicaid expansion states. In the post-expansion time period there were 5571 residing in the MES and 2985 in the non-MES. DID analysis revealed a decrease in stage IV melanoma at diagnosis (DID -0.222, p < 0.001) between MES and non-MES before and after Medicaid expansion. After expansion, in stage IV, the occurrence of primary surgery was 0.42 in non-MES and 0.44 (difference 0.02); DID analysis was not statistically significant. The use of immunotherapy in MES was significantly higher than in non-MES after expansion (p < 0.001), although DID analysis did not reveal a statistically significant difference. DID analysis showed a statistically significant decrease in 3-year mortality (DID -0.05, p = 0.001) between MES and non-MES before and after Medicaid expansion.

CONCLUSIONS

This study revealed the positive impact of the ACA's Medicaid expansion on melanoma stage at presentation, highlighting the importance of public health policies in reducing disparities in mortality rates and early-stage diagnoses. Future research should explore additional barriers to care and evaluate the long-term outcomes of Medicaid expansion to optimize cancer care for vulnerable populations.

Race norming and biases in surgical oncology care

Disparities in surgical oncology care may be due to race/ethnicity. Race norming, defined as the adjustment of medical assessments based on an individual's race/ethnicity, and implicit bias are specifically explored in this focused systematic review. We aim to examine how race norming and bias impact oncologic care and postsurgical outcomes, particularly in Black patient populations, while providing potential strategies to improve equitable and inclusive care.

Socioeconomic disparities in reception of limb-sparing surgery versus amputation for lower extremity sarcoma

BACKGROUND

In lower extremity sarcoma treatment, limb salvage approaches present superior alternatives to amputation due to reduced postoperative morbidity and improved quality of life. This study provides a novel analysis of socioeconomic disparities that may affect reception of limb-sparing surgery.

METHODS

Patients with lower extremity bone or soft tissue sarcoma who received either limb-sparing surgery or amputation from 2007 to 2021 were identified in the Surveillance, Epidemiology and End Results (SEER) database. Demographic, socioeconomic, and oncologic variables were collected for each patient. Multivariate binary logistic regression was conducted to assess preoperative demographic and oncologic risk factors for amputation (p < 0.05).

RESULTS

A total of 6465 patients were identified in the final cohort, 586 (9.1%) of whom received amputation. After controlling for tumor size, stage, and neoadjuvant therapy administration, non-Hispanic American Indian/Alaskan Native race/ethnicity predicted the highest odds of amputation (OR: 1.78, 95% CI: 1.12-2.85, p = 0.015). Nonmetropolitan residence (OR: 1.69, 95% CI: 1.43-2.00, p < 0.001) also conferred higher risk of amputation compared with residence in a large metropolitan area. Overall, amputation was associated with a higher risk of ten-year cancer-specific mortality (p < 0.001) even when controlled by sociodemographic and clinical characteristics.

CONCLUSIONS

There are significant disparities in limb-sparing surgery and amputation rates in lower extremity sarcoma management, even when accounting for differences in baseline oncologic characteristics. Further study into socioeconomic drivers of these trends will allow the development of initiatives that improve disparities in reconstructive outcomes.

Socioeconomic and demographic factors predictive of same day access utilization in outpatient radiation oncology

PURPOSE

Access to medical care extends to not only the timely and appropriate receipt of services but also addresses inclusivity and underlying determinants of health. Given that patients from disadvantaged backgrounds have been shown to be more likely to experience delays in care, a same day access scheduling initiative was proposed to address this equity issue. Therefore, this study aims to evaluate our experience, focusing on identifying socioeconomic and demographic patterns of same day access utilization.

DESIGN/METHODOLOGY/APPROACH

From March 2021 to January 2023, all patients referred for new consultation to a tertiary care-based radiation oncology department were offered same day appointments as part of a prospective pilot initiative. Descriptive statistics were used to identify factors predictive of utilization.

FINDINGS

On multivariate analysis, patient characteristics independently associated with higher odds of same day access utilization included low-income status ([OR] = 3.70, 95% CI (1.47-6.14)) and Black or Latino race ([OR] = 4.05, 95% CI: 1.72-9.11).

RESEARCH LIMITATIONS/IMPLICATIONS

While we were unable to acquire data on actual clinical outcomes for patients opting for same day appointments, the enthusiasm for this program was obvious.

PRACTICAL IMPLICATIONS

Patients from disadvantaged backgrounds and vulnerable segments of the population were more likely to elect for same day appointments. Implications on health equity are discussed.

SOCIAL IMPLICATIONS

Patient-centered approaches to overcome barriers of access can potentially help ensure that care is equitable.

ORIGINALITY/VALUE

Our findings, representing the first published data analyzing a longitudinal experience with same day appointments in oncology, strongly suggest that certain disadvantaged populations may benefit more from access initiatives.

Medicaid expansion and palliative care for advanced-stage liver cancer

BACKGROUND

Medicaid expansion (ME) has contributed to transforming the United States healthcare system. However, its effect on palliative care of primary liver cancers remains unknown. This study aimed to evaluate the association between ME and the receipt of palliative treatment in advanced-stage liver cancer.

METHODS

Patients diagnosed with stage IV hepatocellular carcinoma or intrahepatic cholangiocarcinoma were identified from the National Cancer Database and divided into pre-expansion (2010-2013) and postexpansion (2015-2019) cohorts. Logistic regression identified predictors of palliative treatment. Difference-in-difference (DID) analysis assessed changes in palliative care use between patients living in ME states and patients living in non-ME states.

RESULTS

Among 12,516 patients, 4582 (36.6%) were diagnosed before expansion, and 7934 (63.6%) were diagnosed after expansion. Overall, rates of palliative treatment increased after ME (18.1% [pre-expansion] vs 22.3% [postexpansion]; P < .001) and are more pronounced among ME states. Before expansion, only cancer type and education attainment were associated with the receipt of palliative treatment. Conversely, after expansion, race, insurance, location, cancer type, and ME status (odds ratio [OR], 1.23; 95% CI, 1.06-1.44; P = .018) were all associated with palliative care. Interestingly, the odds were higher if treatment involved receipt of pain management (OR, 2.05; 95% CI, 1.23-2.43; P = .006). Adjusted DID analysis confirmed increased rates of palliative treatment among patients living in ME states relative to non-ME states (DID, 4.4%; 95% CI, 1.2-7.7; P = .008); however, racial disparities persist (White, 5.6; 95% CI, 1.4-9.8; P = .009; minority, 2.6; 95% CI, -2.5 to 7.6; P = .333).

CONCLUSION

The implementation of ME contributed to increased rates of palliative treatment for patients residing in ME states after expansion. However, racial disparities persist even after ME, resulting in inequitable access to palliative care.

American Cancer Society's report on the status of cancer disparities in the United States, 2023

In 2021, the American Cancer Society published its first biennial report on the status of cancer disparities in the United States. In this second report, the authors provide updated data on racial, ethnic, socioeconomic (educational attainment as a marker), and geographic (metropolitan status) disparities in cancer occurrence and outcomes and contributing factors to these disparities in the country. The authors also review programs that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. There are substantial variations in risk factors, stage at diagnosis, receipt of care, survival, and mortality for many cancers by race/ethnicity, educational attainment, and metropolitan status. During 2016 through 2020, Black and American Indian/Alaska Native people continued to bear a disproportionately higher burden of cancer deaths, both overall and from major cancers. By educational attainment, overall cancer mortality rates were about 1.6-2.8 times higher in individuals with ≤12 years of education than in those with ≥16 years of education among Black and White men and women. These disparities by educational attainment within each race were considerably larger than the Black-White disparities in overall cancer mortality within each educational attainment, ranging from 1.03 to 1.5 times higher among Black people, suggesting a major role for socioeconomic status disparities in racial disparities in cancer mortality given the disproportionally larger representation of Black people in lower socioeconomic status groups. Of note, the largest Black-White disparities in overall cancer mortality were among those who had ≥16 years of education. By area of residence, mortality from all cancer and from leading causes of cancer death were substantially higher in nonmetropolitan areas than in large metropolitan areas. For colorectal cancer, for example, mortality rates in nonmetropolitan areas versus large metropolitan areas were 23% higher among males and 21% higher among females. By age group, the racial and geographic disparities in cancer mortality were greater among individuals younger than 65 years than among those aged 65 years and older. Many of the observed racial, socioeconomic, and geographic disparities in cancer mortality align with disparities in exposure to risk factors and access to cancer prevention, early detection, and treatment, which are largely rooted in fundamental inequities in social determinants of health. Equitable policies at all levels of government, broad interdisciplinary engagement to address these inequities, and equitable implementation of evidence-based interventions, such as increasing health insurance coverage, are needed to reduce cancer disparities.

The Impact of Medicaid Expansion on Early-Stage Pancreatic Adenocarcinoma at High- Versus Low-Volume Facilities

INTRODUCTION

While Medicaid Expansion (ME) has improved healthcare access, disparities in outcomes after volume-dependent surgical care persist. We sought to characterize the impact of ME on postoperative outcomes among patients undergoing resection for pancreatic ductal adenocarcinoma (PDAC) at high-volume (HVF) versus low-volume (LVF) facilities.

METHODS

Patients who underwent resection for PDAC were identified from the National Cancer Database (NCDB; 2011-2018). HVF was defined as ≥20 resections/year. Patients were divided into pre- and post-ME cohorts, and the primary outcome was textbook oncologic outcomes (TOO). Difference-in-difference (DID) analysis was used to assess changes in TOO achievement among patients living in ME versus non-ME states.

RESULTS

Among 33,764 patients who underwent resection of PDAC, 19.1% (n = 6461) were treated at HVF. Rates of TOO achievement were higher at HVF (HVF: 45.7% vs. LVF: 32.8%; p < 0.001). On multivariable analysis, undergoing surgery at HVF was associated with higher odds of achieving TOO (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.49-1.72) and improved overall survival (OS) [hazard ratio (HR) 0.96, 95% CI 0.92-0.99]. Compared with patients living in non-ME states, individuals living in ME states were more likely to achieve TOO on adjusted DID analysis (5.4%, p = 0.041). Although rates of TOO achievement did not improve after ME at HVF (3.7%, p = 0.574), ME contributed to markedly higher rates of TOO among patients treated at LVF (6.7%, p = 0.022).

CONCLUSIONS

Although outcomes for PDAC remain volume-dependent, ME has contributed to significant improvement in TOO achievement among patients treated at LVF. These data highlight the impact of ME on reducing disparities in surgical outcomes relative to site of care.

Changes in cancer mortality after Medicaid expansion and the role of stage at diagnosis

BACKGROUND

Medicaid expansion is associated with improved survival following cancer diagnosis. However, little research has assessed how changes in cancer stage may mediate improved cancer mortality or how expansion may have decreased population-level cancer mortality rates.

METHODS

Nationwide state-level cancer data from 2001 to 2019 for individuals ages 20-64 years were obtained from the combined Surveillance, Epidemiology, and End Results National Program of Cancer Registries (incidence) and the National Center for Health Statistics (mortality) databases. We estimated changes in distant stage cancer incidence and cancer mortality rates from pre- to post-2014 in expansion vs nonexpansion states using generalized estimating equations with robust standard errors. Mediation analyses were used to assess whether distant stage cancer incidence mediated changes in cancer mortality.

RESULTS

There were 17 370 state-level observations. For all cancers combined, there were Medicaid expansion-associated decreases in distant stage cancer incidence (adjusted odds ratio = 0.967, 95% confidence interval  = 0.943 to 0.992; P = .01) and cancer mortality (adjusted odds ratio = 0.965, 95% confidence interval = 0.936 to 0.995; P = .022). This translates to 2591 averted distant stage cancer diagnoses and 1616 averted cancer deaths in the Medicaid expansion states. Distant stage cancer incidence mediated 58.4% of expansion-associated changes in cancer mortality overall (P = .008). By cancer site subgroups, there were expansion-associated decreases in breast, cervix, and liver cancer mortality.

CONCLUSIONS

Medicaid expansion was associated with decreased distant stage cancer incidence and cancer mortality. Approximately 60% of the expansion-associated changes in cancer mortality overall were mediated by distant stage diagnoses.

Gender disparities in lung cancer incidence in the United States during 2001-2019

Lung cancer ranks as one of the top malignancies and the leading cause of cancer death in both males and females in the US. Using a cancer database covering the entire population, this study was to determine the gender disparities in lung cancer incidence during 2001-2019. Cancer patients were obtained from the National Program of Cancer Registries (NPCR) and Surveillance, Epidemiology and End Results (SEER) database. The SEER*Stat software was applied to calculate the age-adjusted incidence rates (AAIR). Temporal changes in lung cancer incidence were analyzed by the Joinpoint software. A total of 4,086,432 patients (53.3% of males) were diagnosed with lung cancer. Among them, 52.1% were 70 years or older, 82.7% non-Hispanic white, 39.7% from the South, and 72.6% non-small cell lung cancer (NSCLC). The AAIR of lung cancer continuously reduced from 91.0 per 100000 to 59.2 in males during the study period, while it increased from 55.0 in 2001 to 56.8 in 2006 in females, then decreased to 48.1 in 2019. The female to male incidence rate ratio of lung cancer continuously increased from 2001 to 2019. Gender disparities were observed among age groups, races, and histological types. In those aged 0-54 years, females had higher overall incidence rates of lung cancer than males in recent years, which was observed in all races (except non-Hispanic black), all regions, and adenocarcinoma and small cell (but not squamous cell). Non-Hispanic black females aged 0-54 years had a faster decline rate than males since 2013. API females demonstrated an increased trend during the study period. Lung cancer incidence continues to decrease with gender disparities among age groups, races, regions, and histological types. Continuous anti-smoking programs plus reduction of related risk factors are necessary to lower lung cancer incidence further.

The Impact of Medicaid Expansion on Early-Stage Hepatocellular Carcinoma Care

INTRODUCTION

The impact of Medicaid expansion (ME) on hepatocellular carcinoma (HCC) remains controversial, and heterogeneous effects on care processes may relate to sociodemographic factors. We sought to evaluate the association between ME and receipt of surgery in early-stage HCC.

METHODS

Patients diagnosed with early-stage HCC between 40 and 64 years of age were identified from the National Cancer Database and divided into pre- (2004-2012) and post- (2015-2017) expansion cohorts. Logistic regression was used to identify predictors of surgical treatment. Difference-in-difference (DID) analysis assessed changes in surgical treatment between patients living in ME and non-ME states.

RESULTS

Among 19,745 patients, 12,220 (61.9%) were diagnosed before ME and 7525 (38.1%) after. Although overall utilization of surgery decreased after expansion (ME, pre-expansion: 62.2% versus post-expansion: 51.6%; non-ME, pre-expansion: 62.1% versus post-expansion: 50.8%, p < 0.001), this trend varied relative to insurance status. Notably, receipt of surgery increased among uninsured/Medicaid patients living in ME states after expansion (pre-expansion: 48.1%, post-expansion: 52.3%, p < 0.001). Moreover, treatment at academic or high-volume facilities increased the likelihood of undergoing surgery before expansion. After expansion, treatment at an academic facility and living in an ME state (OR 1.28, 95% CI 1.07-1.54, p < 0.01) were predictors of surgical treatment. DID analysis demonstrated increased utilization of surgery for uninsured/Medicaid patients living in ME states relative to non-ME states (uninsured/Medicaid: 6.4%, p < 0.05), although no differences were noted among patients with other insurance statuses (overall: 0.7%, private: -2.0%, other: 0.3%, all p > 0.05).

CONCLUSIONS

Implementation of ME heterogeneously impacted utilization of care in early-stage HCC. Notably, uninsured/Medicaid patients residing in ME states demonstrated increased utilization of surgical treatment after expansion.

Neighborhood factors and triple negative breast cancer: The role of cumulative exposure to area-level risk factors

BACKGROUND

Despite similar incidence rates among Black and White women, breast cancer mortality rates are 40% higher among Black women. More than half of the racial difference in breast cancer mortality can be attributed to triple negative breast cancer (TNBC), an aggressive subtype of invasive breast cancer that disproportionately affects Black women. Recent research has implicated neighborhood conditions in the etiology of TNBC. This study investigated the relationship between cumulative neighborhood-level exposures and TNBC risk.

METHODS

This single-institution retrospective study was conducted on a cohort of 3316 breast cancer cases from New Castle County, Delaware (from 2012 to 2020), an area of the country with elevated TNBC rates. Cases were stratified into TNBC and "Non-TNBC" diagnosis and geocoded by residential address. Neighborhood exposures included census tract-level measures of unhealthy alcohol use, metabolic dysfunction, breastfeeding, and environmental hazards. An overall cumulative risk score was calculated based on tract-level exposures.

RESULTS

Univariate analyses showed each tract-level exposure was associated with greater TNBC odds. In multivariate analyses that controlled for patient-level race and age, tract-level exposures were not associated with TNBC odds. However, in a second multivariate model that included patient-level variables and considered tract-level risk factors as a cumulative exposure risk score, each one unit increase in cumulative exposure was significantly associated with a 10% increase in TNBC odds. Higher cumulative exposure risk scores were found in census tracts with relatively high proportions of Black residents.

CONCLUSIONS

Cumulative exposure to neighborhood-level risk factors that disproportionately affect Black communities was associated with greater TNBC risk.

Updated racial disparities in incidence, clinicopathological features and prognosis of hypopharyngeal squamous carcinoma in the United States

OBJECTIVE

This study was to determine the racial disparities in incidence, clinicopathological features and prognosis of hypopharyngeal squamous cell carcinoma (HPSCC) in the US.

METHODS

The National Program of Cancer Registries and Surveillance, Epidemiology, and End Results (SEER) database was used to determine racial disparity in age adjusted incidence rate (AAIR) of HPSCC and its temporal trend during 2004-2019. Using the separate SEER 17 database, we further evaluated racial disparity in clinicopathological features, and in prognosis using Kaplan-Meier curves and Cox proportional hazard models.

RESULTS

HPSCC accounted for 95.8% of all hypopharyngeal cancers and occurred much more frequently in males. Its incidence decreased in both male and females, in male non-Hispanic white (NHW), non-Hispanic black (NHB) and Hispanic as well as female NHW and NHB during the study period. NHB had the highest, whereas non-Hispanic Asian or Pacific Islanders (API) had comparable and the lowest incidence in both males and females. Among 6,172 HPSCC patients obtained from SEER 17 database, 80.6% were males and 83.9% were at the advanced stages III/IV. Five-year cancer specific and overall survival rates were 41.2% and 28.9%, respectively. NHB patients were more likely to be younger, unmarried, from the Southern region, larger sized tumor, and at the stage IV, but less likely to receive surgery. They also had higher proportions of dying from HPSCC and all causes. Multivariate analyses revealed that NHB with HPSCC at the locally advanced stage had both significantly worse cancer specific and overall survival compared with NHW, but not at early stage (I/II) or distant metastatic stage. Hispanic patients had significantly better prognosis than NHW at locally advanced and metastatic stages. NHW and API had comparable prognoses.

CONCLUSIONS

HPSCC displays continuously decreased incidence and racial disparity. The majority of the disease is diagnosed at the advanced stage. NHB have the highest burden of HPSCC and a worse prognosis. More studies are needed to curtail racial disparity and improve early detection.

In pursuit of equity in cancer care: moving beyond the Affordable Care Act

Although Medicaid Expansion under the Patient Protection and Affordable Care Act (ACA) has been associated with many improvements for patients with cancer, Snyder et al. provide evidence demonstrating the persistence of racial disparities in cancer. This Editorial describes why insurance coverage alone does not ensure access to health care, highlights various manifestations of structural racism that constitute barriers to access beyond the direct costs of care, and calls for not just equality, but equity, in cancer care.