Breast Cancer Outcomes Improved in States With Medicaid Expansion

Medicaid expansion has been associated with improved care and increased survival rates for patients with certain breast cancers, but future studies should focus on whether Medicaid expansion mitigates the disparities between Black and non-White patients. | Image Credit: wladimir1804- stock.adobe.com

Medicaid expansion has been linked to improved care and increased survival rates for patients with stage III hormone receptor (HR)–negative, HER2-positive (HR–/HER+) breast cancers, according to a study published in the Journal of National Comprehensive Cancer Network.¹

Breast cancer treatment has significantly evolved over the past several decades with genomic testing, radiation therapy, surgery, and systemic therapy.² However, accessibility of these life-saving treatments is typically expensive, preventing underserved communities from using them. A study comparing direct and indirect costs of breast cancer and associated implications found the US had the highest costs compared with Canada and Western European countries.³

High treatment costs are based on the type of insurance plans patients are covered under.¹ Patients who are underinsured or uninsured are limited in targeted treatment options due to the lack of coverage. The Affordable Care Act sought to address this issue through expanded health insurance options.

Medicaid expansion allows adults with income up to 138% of the federal poverty level (approximately $20,780 annually for an individual and $35,630 for a family of 3) to receive Medicaid coverage.⁴ Most states have adopted Medicaid expansion, with only 10 states that have not. Research has found an increase in coverage, resulting in healthier and more financially secure patients.

“We evaluated the association of Medicaid expansion with receipt of guideline-concordant treatment, time to treatment initiation, and 2-year overall survival among nonelderly women with newly diagnosed HR-negative and HER2-positive breast cancer,” wrote the study authors.¹

The study utilized data from the National Cancer Database, a hospital-based cancer registry in the US that is combined with the American College of Surgeons and the American Cancer Society. Participants included women between 18 and 62 years who received an HR– or HER2+ breast cancer diagnosis between 2010 and 2018.

Of the 31,401 patients with HR–/HER2+ breast cancer, there were 19,248 living in Medicaid expansion states and 12,153 women were living in nonexpansion states. Patients living in nonexpansion states had an increased likelihood of being racial or ethnic minorities (36.2% vs 32%).

Patients in nonexpansion states were more likely to be uninsured (6.4% vs 2.4%), live in lower income regions (9.5% vs 5.7%) and nonmetropolitan areas (14.5% vs 9.5%), and were not treated at academic cancer programs (29.1% vs 35%) compared with patients in expansion states. The number of uninsured patients decreased more in expansion states compared with nonexpansion states (3.2% to 1.9% vs 6.5% to 6.3%).

Following Medicaid expansion, the 2-year survival rate increased from 93.9% to 95%. The improvement was greatest among patients newly diagnosed with stage III disease, who experienced a 3.81 percentage point (ppt) increase (95% CI, 0.82-6.80). There was also a 0.58 ppt increase in the receipt of guideline-concordant treatment with Medicaid expansion (ppt, 95% CI, 0.01-1.16).

Medicaid expansion was linked to both initiation of guideline-concordant treatment for less than 60 days from diagnosis (difference in differences [DID], 2.43 ppt; 95% CI, 0.68-4.18), as well as less than 90 days from diagnosis (DID, 1.41 ppt; 95% CI, 0.24-2.58).

“This study reinforces the important role Medicaid expansion plays in ensuring that women newly diagnosed with HR-negative, HER2-positive breast cancer have equitable access to the health care services they need-especially when prognosis depends on access to treatment,” said Millicent Gorham, CEO of the Alliance for Women’s Health and Prevention, in a statement.⁵

Study limitations were largely due to the hospital-based cancer registry data that were not population based and do not allow analysis for generalizability.¹ The study focused on overall survival measurements, but the data registry fails to include data on cause of death. Additionally, disparities between receipt of treatment or survival by age, race/ethnicity, comorbidity burden, or type of treatment facility was based on small sample sizes.

Medicaid expansion decreased the receipt of guideline-concordant treatment, reduced delays in treatment initiation, and improved 2-year survival among nonelderly women with newly diagnosed HR–/HER2+ breast cancer. Future studies should focus on determining whether Medicaid expansion mitigates the disparities between Black and non-White patients.

“Expanding insurance coverage to individuals with cancer can allow them to benefit from access to life-saving treatments,” concluded the study authors.

References

1. Shi KS, Ji X, Jiang C, et al. Association of Medicaid expansion with timely receipt of treatment and survival among patients with HR-negative, HER2-positive breast cancer. J Natl Compr Canc Netw. 2024;22(00):1-7. doi:10.6004/jnccn.2024.7041

2. Wilkinson AN, Seely JM, Rushton M, et al. Capturing the true cost of breast cancer treatment: molecular subtype and stage-specific per-case activity-based costing. Current Oncology. 2023;30(9):7860-7873. doi:10.3390/curroncol30090571

3. FranklinM, PollardD, SahJ, et al. Direct and indirect costs of breast cancer and associated implications: asystematic review. Adv Ther. 2024;41:2700-2722. doi:10.1007/s12325-024-02893-y

4. Harker L. Medicaid expansion: frequentlyasked questions. Center on Budget and Policy Priorities. March 18, 2024. Accessed October 23, 2024. https://www.cbpp.org/research/health/medicaid-expansion-frequently-asked-questions-0

5. New JNCCN study suggests Medicaid expansion improves cancer care and survival for people with aggressive type of breast cancer. News release. National Comprehensive Cancer Network; October 24, 2024. Accessed October 24, 2024. https://www.nccn.org/home/news