ASCO 2021 Recap: COVID-19, Cancer, and Medicaid

Telehealth Will Stay, but Not for Every Visit, Oncologists Report

Results of a survey reported during the annual meeting of the American Society of Clinical Oncology (ASCO) found that almost all cancer specialists will keep using telehealth after the pandemic ends—but perhaps not for every type of visit.

ASCO, which held a virtual meeting for the second year due to the COVID-19 pandemic, shared results commissioned by its Telehealth Survey Task Force. Christopher Manz, MD, MSHP, a
medical oncologist with Dana-Farber Cancer Institute, said 200 physicians completed the survey; respondents offered a good geographic distribution, representing 42 states.

Respondents were evenly split between those in practices of 20 clinicians or fewer and those with more than 20 clinicians. Of those taking the survey, 72% were medical oncologists.

Those who responded said using telehealth for symptom management and survivorship care has clear benefits, but 68% said it fell short for first-time visits, when doctors prefer to see patients in person. Only 8% of the respondents said they did not plan to use telehealth at all after the pandemic.

Respondents were asked how they used telehealth for different types of visits as the pandemic hit a peak in January 2021. At that time, 51% said they were using the technology for at least half of
survivorship visits in the past 30 days; by contrast, only 19% said they had used telehealth for at least half of their goals-of-care conversations, when topics such as palliative care or advanced
care planning may be discussed.

Manz said the appropriateness of using telehealth for a specific type of visit wasn’t the only consideration.

“Respondents reported that a number of patient, clinician, practice, and financial factors were barriers to using telehealth,” he said. Most frequently cited: patients’ access to technology,
and the patients’ limited proficiency with telehealth technology. Both were cited by about 80% of clinicians.

“Overall, respondents in this small survey reported telehealth utilization, quality of telehealth, and preferences for postpandemic telehealth use that often varied with the type of visit,” Manz said. “However, clinicians highlighted a number of barriers that can inform policies around telehealth in the coming months and years.”

Reference

Manz C, Baxter NN, duPont NC, et al; ASCO Telehealth Disparities Taskforce. Patterns of telehealth
utilization during the COVID-19 pandemic and preferences for post-pandemic telehealth use:
a national survey of oncology clinicians. J Clin Oncol. 2021;39(Suppl 15):abstr 1580. doi:10.1200/
JCO.2021.39.15_suppl.1580

Impact of COVID-19 on Disparities in Cancer Outcomes Spans Various Groups of Patients

Patients with cancer had different outcomes during the COVID-19 pandemic depending on their
ethnic background or economic status, according to a pair of studies presented during the 2021
American Society of Clinical Oncology (ASCO) annual meeting.

Abstracts revealed that end-of-life experiences are worse for patients with Medicaid than they
are for patients with commercial insurance, and that Black patients with breast cancer fare poorly
compared with other ethnic groups when it comes COVID-19 outcomes.

Disparities in health outcomes by race and ethnicity or have been studied for years, but the
arrival of COVID-19 has added a new dimension and elevated awareness about health and coverage gaps as the pandemic made its way through the country.

BREAST CANCER AND COVID-19. With Black and Hispanic patients having a higher risk of acquiring the virus that causes COVID-19, investigators of the first study abstract aimed to see how 1000 patients of different ethnicities with breast cancer fare after contracting the disease.¹

Across all ethnic groups, Black patients were significantly more likely to have more severe illness
and die of the virus. Black patients were more likely than White and Hispanic patients to be hospitalized for COVID-19 (49% vs 34% vs 34%, respectively) and require mechanical ventilation (9% vs 3% vs 5%, respectively). Both 30-day (9% vs 6% vs 4%, respectively) and total mortality (12% vs 8% vs 5%, respectively) were higher among Black patients than White and Hispanic patients.

“This is the largest study to show significant differences in COVID-19 outcomes by racial/
ethnic groups of women with [breast cancer]. The adverse outcomes in [non-Hispanic Blacks] could
be due to higher moderate to severe COVID-19 at presentation and preexisting comorbidities,” wrote the investigators, noting that more than half (54%) of the Black patients in their study had obesity and 31% had diabetes.

The researchers added: “[Hispanics] did not have worse outcomes despite having more active
disease and recent anti-cancer therapy, including with cytotoxic chemotherapy—potentially due to
younger age and nonsmoking status.”

Hispanics were significantly younger than the other patients, with a median age of 54 years
compared with 63 years for White patients and 62 years for Black patients. Seventy-eight percent of
Hispanics reported being never smokers compared with 62% of White patients and Black patients.
The study also included a small group of Asian American and Pacific Islander (AAPI) patients
(n = 35), who had more severe COVID-19 and inferior outcomes compared with White patients.
The authors noted that these differences were statistically significant despite the small sample size
of AAPI patients.

CANCER, COVID-19, AND INSURANCE STATUS. The second abstract presented at ASCO showed
that the impact of COVID-19 on cancer outcomes also varies based on economic status, finding that
patients with cancer on Medicaid are more likely than commercially insured patients with cancer to
die at home without hospice.² The findings come from over 600 patients in Washington state, the earliest COVID-19 epicenter in the country. Compared with commercially insured patients, those on Medicaid were 15.8% more likely to die at home without the end-of-life care.

“Following COVID, Medicaid patients place of death shifted from hospital to homes, but without
an increase in the use of home hospice services,” explained the researchers. “In contrast, place of
death and hospice use among commercial patients did not significantly change. This widening disparity in home deaths without hospice services raises concerns that the pandemic disproportionately worsened end of life experience for low income patients with cancer.”

Prior to the pandemic (2017-2019), patients with Medicaid were more likely than younger patients
with commercial insurance to die in the hospital. However, between March and June 2020, the probability of older patients dying in the hospital dropped by 12% and the probability of these patients dying at home without hospice increased by 11% compared with the period before COVID-19.

References

1. Nagaraj G, Accordino M, French B, et al. Racial and ethnic disparities among patients with breast cancer and COVID-19. J Clin Oncol. 2021;39:(suppl_15) abstr 6500. doi:10.1200/JCO.2021.39.15_suppl.6500
2. Panattoni L, Li L, Sun Q, et al. Medicaid patients more likely to die at home without hospice during the pandemic versus before, exacerbating disparities with commercially insured patients. J Clin Oncol. 2021;39:(suppl_15) abstr 6502. doi:10.1200/JCO.2021.39.15_suppl.6502

Higher Medicaid Income Limits Linked to Longer Cancer Survival

States' higher Medicaid income limits—allowing more people to have health coverage—had
better cancer survival rates among those newly diagnosed with cancer, according to study released
this week ahead of the annual meeting of the American Society of Clinical Oncology (ASCO).
The study tracks 1.5 million adults who were diagnosed with cancer between 2010 and 2013, just
before the effects of Medicaid expansion, allowed states to include households earning up to 138% of the federal poverty line (FPL). But some states opted not to participate, and because Medicaid has always been a shared program between federal and state governments, there has been wide variation in income limits for Medicaid over the past decade for adults aged 19 to 64 years.

Using the National Cancer Database, researchers tracked the patients through December 31, 2017, for up to 8 years of follow-up. They put states into 3 categories based on their Medicaid income limit: (1) 50% of the FPL or less, (2) 51% to 137%, or (3) 138% of the FPL or greater. The study team compared results for 17 common cancers. Among those diagnosed with early-stage breast cancer, the death rate due to any cause was 31% higher in states with Medicaid income eligibility limits capped at 50% of FPL, and 17% higher in states with limits between 51% and 137% FPL, compared with similar patients in the 11 states with Medicaid income eligibility limits of 138% FPL or greater prior to 2014.

This is not the first study presented at ASCO linking Medicaid expansion to improvements in cancer care. A late-breaking abstract presented in 2019 found that expansion led to better cancer care for Black patients newly diagnosed with cancer, including the ability to get timely care. Lead author Jingxuan Zhao, MPH, an associate scientist at the American Cancer Society, said the variation that exists today was present at the start of the study as well. In Texas, home to the largest number of uninsured, the Medicaid eligibility cap was only 27% of the FPL.

The number of states opting for Medicaid expansion has increased since 2014, and now stands at
38 plus the District of Columbia. The remaining 12 include some of the poorest states in the country, which have high rates of comorbidities. Congress recently offered more incentives to woo these states to expand Medicaid under the Affordable Care Act.

“This study shows that states with expanded Medicaid income eligibility limits have improved
cancer survival rates, consistent across cancer type and stage. Health insurance coverage is associated with improved access to cancer prevention, diagnosis, and treatment, allowing us better opportunities to provide the right care to the right patient at the right time,” said ASCO President Lori J. Pierce, MD, FASTRO, FASCO.

“I think these data can be used to encourage those states who have chosen not to expand Medicaid
coverage to strongly reconsider, since people who are uninsured are very likely to forego screening, and miss detection of early lesions, when a cure would be far more likely,” Pierce said.

“Those who are uninsured are unlikely to receive cancer care. And for those who are able to start
cancer treatment, they’re unlikely to complete their cancer here. So, equity of care is very, very critical.”

Reference

1. Zhao J, Han X, Nogueria L, et al. Association of state Medicaid income eligibility limits and long-term survival after cancer diagnosis in the United States. J Clin Oncol. 2021;39(suppl 15):6512. doi:10.1200/JCO.2021.39.15_suppl.6512