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Missed Precision: Gaps in Molecular Profiling Among Medicaid Patients With Estrogen Receptor-Positive, Human
Trisha Lal1, Long Vu2, Reine Abou Zeidane3
1Department of Surgery, University Hospitals, Cleveland Medical Center, Cleveland, OH.
Purpose:
Molecular profiling (MP) informs precision oncology in estrogen receptor-positive, human epidermal growth factor receptor 2-negative (ER+/HER2-) breast cancer, yet uptake within Medicaid is poorly characterized. We assessed MP receipt and associated factors among Ohio Medicaid beneficiaries with nonmetastatic ER+/HER2- breast cancer.
Methods:
We conducted a retrospective cohort study using linked Ohio Cancer Incidence Surveillance System and Medicaid claims data. Study patients were age 18-65 years, diagnosed between 2016 and 2020 with localized or regional-stage ER+/HER2- breast cancer, and continuously enrolled in Medicaid for ≥6 months following diagnosis or until death. The primary outcome was MP (Oncotype DX or MammaPrint) within 6 months of diagnosis. Multivariable logistic regression estimated adjusted odds ratios (aORs) for MP by stage, sociodemographics, Medicaid enrollment features (stable enrollment, long-term care [LTC] status), and neighborhood opportunity (Ohio Opportunity Index [OOI]).
Results:
Among 1,988 patients, 752 (37.8%) received MP. In adjusted analyses, MP receipt was lower in regional versus localized disease (aOR, 0.35, 95% CI, 0.28 to 0.42), among Black versus White women (aOR, 0.72, 95% CI, 0.56 to 0.91), among patients with income above versus below the federal poverty level (aOR, 0.73, 95% CI, 0.57 to 0.94), and among Medicaid LTC enrollees versus nonenrollees (aOR, 0.47, 95% CI, 0.33 to 0.66). MP receipt was higher among married versus single patients (aOR, 1.30, 95% CI, 1.01 to 1.67). Stable Medicaid enrollment showed a positive trend (aOR, 1.24, 95% CI, 0.98 to 1.58). OOI was not associated with MP.
Conclusion:
Fewer than 40% of Ohio Medicaid beneficiaries with localized or regional-stage ER+/HER2- breast cancer received MP, with variation by clinical stage and sociodemographic factors. As Medicaid programs face fiscal and policy pressures, health systems should prioritize consistent implementation of clinically indicated MP, particularly among patients with regional-stage disease, Black patients, and long-term Medicaid enrollees.