Association of Medicaid Expansion With Timely Receipt of Treatment and Survival Among Patients With HR-Negative, HER2-Positive Breast Cancer
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Aflac Cancer & Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA
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Aflac Cancer & Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA
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Background: Hormone receptor (HR)–negative, HER2-positive (also called HER2-enriched) breast cancer has no worse prognosis than other breast cancers if it is treated with HER2-targeted therapy. Medicaid expansion under the Affordable Care Act (ACA) has been shown to be associated with improved access to care and outcomes for many cancers, but its association with receipt of care for HR-negative, HER2-positive breast cancer is unknown. We examined the association of Medicaid expansion with receipt of guideline-concordant treatment, time to treatment initiation, and survival among nonelderly women newly diagnosed with HR-negative, HER2-positive breast cancer. Patients and Methods: Women aged 18 to 62 years newly diagnosed with HR-negative, HER2-positive breast cancer between 2010 and 2018 were identified from the National Cancer Database. Outcomes included receipt of stage-based guideline-concordant treatment, timely initiation of treatment (<30 days, <60 days, <90 days from diagnosis), and stage-specific 2-year overall survival. A difference-in-differences (DID) analytic approach compared outcome changes following Medicaid expansion in expansion versus nonexpansion states. Multivariable linear probability models were used to estimate treatment outcomes, and flexible parametric survival models were used to evaluate survival, adjusting for sociodemographic and clinical confounders. Results: A total of 31,401 patients were included. Medicaid expansion was associated with an increase of 0.58 percentage points (ppt; 95% CI, 0.01–1.16) in receipt of guideline-concordant treatment overall, a 2.43-ppt (95% CI, 0.68–4.18) increase in initiating guideline-concordant treatment <60 days after diagnosis, and a 1.17-ppt (95% CI, 0.02–2.32) increase in 2-year survival rate. The increase in 2-year survival associated with Medicaid expansion was most prominent for patients with stage III disease (DID, 3.81; 95% CI, 0.82–6.80). Conclusions: Medicaid expansion was associated with improved care and survival for patients with HR-negative, HER2-positive breast cancer, an aggressive cancer type for which prognosis largely depends on access to effective treatment.
Submitted September 14, 2023; final revision received March 28, 2024; accepted for publication May 20, 2024. Published online October 23, 2024.
Author contributions: Study concept & design: All authors. Data interpretation: All authors. Formal analysis: Shi, Han. Project administration: Han. Writing—original draft: Shi. Writing—review & editing: All authors.
Disclosures: Dr. Castellino has disclosed serving as a scientific advisor for Seattle Genetics. Dr. Yabroff has disclosed serving as a scientific advisor for Flatiron Health. Dr. Han has disclosed receiving grant/research support from AstraZeneca. The remaining 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 work was supported by grant R03CA259665 (X. Ji, S.M. Castellino, X. Han) from the National Cancer Institute of the National Institutes of Health.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. None of the funders had no role in the design of the study; collection, analysis, and interpretation of the data; writing of the manuscript; and decision to submit the manuscript for publication.
Supplementary material: Supplementary material associated with this article is available online at https://doi.org/10.6004/jnccn.2024.7041. 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.
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