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Medicaid Expansion Is Associated with Lower Mortality in Patients with Locally Advanced Breast Cancer
Simran Malhotra1, Daniel X Choi1, Varadan Sevilimedu2
1Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Background:
Studies show that Medicaid expansion leads to timely diagnosis and treatment of early-stage breast cancer; however, no studies have examined its impact on locally advanced breast cancer (LABC). We assessed LABC rates pre- and post-Medicaid expansion, and evaluated overall survival (OS) in LABC patients treated in expansion and non-expansion states.
Methods:
Overall, 5147 National Cancer Database participants age 40-64 years diagnosed with LABC between 2010 and 2017 were allocated into the two cohorts. Demographic/clinical variables were compared using the Wilcoxon rank-sum and Pearson's Chi-square tests. A generalized linear model assessed trends in LABC diagnoses over time, while a Cox proportional hazards model evaluated associations between Medicaid expansion status and OS.
Results:
A total of 3346 and 1801 LABC patients resided in expansion and non-expansion states, respectively. Ninety-one percent of non-expansion patients resided in the Southern United States (p < 0.001) versus 8.2% of expansion patients. Non-expansion patients were more likely to be non-Hispanic Black and/or have lower income (p < 0.001), while expansion patients were more likely to be Asian/Pacific Islander, Hispanic, metropolitan-area residents, and/or academic/research program-treated (p < 0.001). Trimodality therapy use was similarly low between non-expansion and expansion patients (68% and 70%, respectively; p = 0.054), while OS improved in expansion versus non-expansion patients post-policy implementation (p < 0.001). On multivariable analysis, triple-negative subtype (p < 0.001) and residence in a non-expansion state (p = 0.015) were associated with worse survival, while receipt of trimodality therapy (p < 0.001) was associated with improved survival.
Conclusions:
While trimodality therapy was associated with improved survival, less than three-quarters of patients received this treatment in both state types. Medicaid expansion was associated with improved OS in the post-implementation era, suggesting that these changes in Medicaid coverage may positively impact LABC outcomes.
