Medicaid Expansion Linked to Better Survival in Aggressive Breast Cancer

Women with newly diagnosed hormone receptor (HR)-negative, HER2-positive breast cancer were more likely to receive timely treatment and have longer survival in states that participated in Medicaid expansion under the Affordable Care Act, a nationwide study showed.

For over 31,000 women with this aggressive breast cancer, Medicaid expansion was associated with an increase of 0.58 percentage points in receipt of guideline-concordant treatment overall, an increase of 2.43 percentage points in initiation of guideline-concordant treatment less than 60 days after diagnosis, and an increase of 1.17 percentage points in the 2-year survival rate, reported Kewei Sylvia Shi, MPH, of the American Cancer Society, and colleagues.

The biggest increase in 2-year survival associated with Medicaid expansion was among patients with stage III disease, with a difference-in-difference of 3.81 percentage points (95% CI 0.82-6.80), they noted in the Journal of the National Comprehensive Cancer Network.

“Focusing on a common cancer type with effective treatments, this study adds to the growing evidence by demonstrating the positive effects of Medicaid expansion on increased access to care and improved health outcomes among patients with breast cancer,” Shi and colleagues wrote.

Shi told MedPage Today that “improving and increasing health insurance coverage is a key aspect of Medicaid expansion under the Affordable Care Act. We believe it plays a central role in improving access to breast cancer treatment and survival.”

“Other factors may also contribute to the relative improvements in breast cancer treatment and survival after breast cancer diagnosis in Medicaid expansion states compared to non-expansion states,” she added. “Prior research has shown that Medicaid expansion boosts overall state economy, increases utilization of healthcare services, and supports informal caregivers. All of these factors likely improve access to healthcare providers, reduce financial barriers, and make it easier for people to receive timely follow-ups and recommended treatment plans.”

While there were decreases in the receipt of guideline-concordant treatment in both expansion states (98.7% to 98.5%) and non-expansion states (99% to 98.2%), the decrease was smaller in expansion states. Shi suggested that the most likely reason for these decreases is an aging population that is increasing the number of newly diagnosed patients with breast cancer requiring treatment.

“Health insurance requirements, such as prior authorizations, may also contribute to delays in treatment initiation and care delivery,” she said. “Additionally, patient preferences, physician workforce constraints, and increasing complexity of care and adoption of advanced technologies, such as genomic testing prior to treatment initiation, could further delay time to treatment initiation.”

Using data from the National Cancer Database (NCDB), Shi and colleagues identified women ages 18 to 62 who were newly diagnosed with HR-negative, HER2-positive breast cancer between 2010 and 2018 from all 50 states and the District of Columbia. Their analysis included 31,401 patients — 19,248 in non-expansion states and 12,153 in expansion states.

The follow-up period lasted from cancer diagnosis until the date of death or 3 months prior to the implementation of Medicaid expansion for pre-expansion patients, and the date of death or Dec. 31, 2019 for post-expansion patients.

Patients in non-expansion states were more likely to be in a racial/ethnic minority group, uninsured, living in lower-income areas and non-metropolitan areas, and not treated in an academic cancer program compared with patients in expansion states.

The proportion of uninsured patients decreased from 3.2% to 1.9% in expansion states, and from 6.5% to 6.3% in non-expansion states.

Shi and colleagues acknowledged several limitations to their study, including the fact that the NCDB is a hospital-based cancer registry rather than a population-based registry, which limits the generalizability of their findings. In addition, the NCDB lacks data on cause of death, so the authors were unable to evaluate breast-cancer specific deaths.

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