Treatment Patterns and Survival Outcomes in Patients With Breast Cancer on Medicaid, Pre- and Post-Expansion

Authors:
Siran M. Koroukian Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH
Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
Center for Community Health Integration, School of Medicine, Case Western Reserve University, Cleveland, OH

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Weichuan Dong Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH

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Jeffrey M. Albert Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH

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Uriel Kim Center for Community Health Integration, School of Medicine, Case Western Reserve University, Cleveland, OH

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Kirsten Eom Public Health Research Institute, The MetroHealth System and Case Western Reserve University, Cleveland, OH

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Johnie Rose Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
Center for Community Health Integration, School of Medicine, Case Western Reserve University, Cleveland, OH

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Cynthia Owusu Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
Department of Internal Medicine, University Hospitals of Cleveland, School of Medicine, Case Western Reserve University, Cleveland, OH

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Kristine M. Zanotti Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
Department of Obstetrics and Gynecology, Gynecologic Oncology, University Hospitals of Cleveland, School of Medicine, Case Western Reserve University, Cleveland, OH

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Gregory Cooper Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
Department of Internal Medicine, University Hospitals of Cleveland, School of Medicine, Case Western Reserve University, Cleveland, OH

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Jennifer Tsui Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA

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Background: The objective of this study was to evaluate the impact of Medicaid expansion on breast cancer treatment and survival among Medicaid-insured women in Ohio, accounting for the timing of enrollment in Medicaid relative to their cancer diagnosis and post-expansion heterogeneous Medicaid eligibility criteria, thus addressing important limitations in previous studies. Methods: Using 2011–2017 Ohio Cancer Incidence Surveillance System data linked with Medicaid claims data, we identified women aged 18 to 64 years diagnosed with local-stage or regional-stage breast cancer (n=876 and n=1,957 pre-expansion and post-expansion, respectively). We accounted for women’s timing of enrollment in Medicaid relative to their cancer diagnosis, and flagged women post-expansion as Affordable Care Act (ACA) versus non-ACA, based on their income eligibility threshold. Study outcomes included standard treatment based on cancer stage and receipt of lumpectomy, mastectomy, chemotherapy, radiation, hormonal treatment, and/or treatment for HER2-positive tumors; time to treatment initiation (TTI); and overall survival. We conducted multivariable robust Poisson and Cox proportional hazards regression analysis to evaluate the independent associations between Medicaid expansion and our outcomes of interest, adjusting for patient-level and area-level characteristics. Results: Receipt of standard treatment increased from 52.6% pre-expansion to 61.0% post-expansion (63.0% and 59.9% post-expansion in the ACA and non-ACA groups, respectively). Adjusting for potential confounders, including timing of enrollment in Medicaid, being diagnosed in the post-expansion period was associated with a higher probability of receiving standard treatment (adjusted risk ratio, 1.14 [95% CI, 1.06–1.22]) and shorter TTI (adjusted hazard ratio, 1.14 [95% CI, 1.04–1.24]), but not with survival benefits (adjusted hazard ratio, 1.00 [0.80–1.26]). Conclusions: Medicaid expansion in Ohio was associated with improvements in receipt of standard treatment of breast cancer and shorter TTI but not with improved survival outcomes. Future studies should elucidate the mechanisms at play.

Submitted February 22, 2023; final revision received October 19, 2023. accepted for publication October 25, 2023. Published online March 19, 2024.

Author contributions: Study concept and design: Koroukian, Albert, Tsui. Data curation: Koroukian, Dong. Formal analysis: Koroukian, Dong, Albert. Funding acquisition: Koroukian, Albert, Owusu, Zanotti, Cooper, Tsui. Investigation: All authors. Methodology: Koroukian, Dong, Albert. Project administration: Koroukian, Dong. Resources: Koroukian. Software: Dong. Supervision: Koroukian, Albert. Validation: Koroukian, Albert. Visualization: Dong, Kim. Writing—original draft: Koroukian, Dong, Albert. Writing—review and editing: All authors.

Disclosures: The authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Funding: This study was supported by the American Cancer Society (132678-RSGI-19-213-01-CPHPS).

Previous presentation: Results were presented in part at the annual meeting of the American Association for Cancer Research Conference on The Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; September 16–19, 2022; Philadelphia, PA.

Supplementary material: Supplementary material associated with this article is available online at https://doi.org/10.6004/jnccn.2023.7104. The supplementary material has been supplied by the author(s) and appears in its originally submitted form. It has not been edited or vetted by JNCCN. All contents and opinions are solely those of the author. Any comments or questions related to the supplementary materials should be directed to the corresponding author.

Correspondence: Siran M. Koroukian, PhD, Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue WG-43, Cleveland, OH 44106-4945. Email: skoroukian@case.edu

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