Impact of affordable care act on the treatment and outcomes for stage-IV colorectal cancer

• Published in: Cancer treatment and research communications Vol. 24; p. 100204
• Main Authors: Jayakrishnan, Thejus T, Bakalov, Veli, Chahine, Zena, Finley, Gene, Monga, Dulabh, Wegner, Rodney E
• Format: Journal Article
• Language: English
• Published: England Elsevier Ltd 2020; Elsevier
• Subjects: Adenocarcinoma - diagnosis; Adenocarcinoma - mortality; Adenocarcinoma - pathology; Adenocarcinoma - therapy; Affordable care act; African Americans - statistics & numerical data; Aged; Chemotherapy; Colonic Neoplasms - diagnosis; Colonic Neoplasms - mortality; Colonic Neoplasms - pathology; Colonic Neoplasms - therapy; Colorectal cancer; European Continental Ancestry Group - statistics & numerical data; Health policy; Health Services Accessibility - legislation & jurisprudence; Health Services Accessibility - statistics & numerical data; Health Services Accessibility - trends; Health Status Disparities; Healthcare Disparities - legislation & jurisprudence; Healthcare Disparities - statistics & numerical data; Hispanic Americans - statistics & numerical data; Humans; Insurance; Insurance Coverage - legislation & jurisprudence; Insurance Coverage - statistics & numerical data; Kaplan-Meier Estimate; Medicaid; Medicaid - statistics & numerical data; Medicare; Middle Aged; Neoplasm Staging; Patient Protection and Affordable Care Act; Rectal Neoplasms - diagnosis; Rectal Neoplasms - mortality; Rectal Neoplasms - pathology; Rectal Neoplasms - therapy; Retrospective Studies; Social determinants; Socioeconomic Factors; Survival; Time-to-Treatment - statistics & numerical data; United States - epidemiology; United States; Chemotherapy; Affordable care act; Health policy; Medicare; Social determinants; Insurance; Colorectal cancer; Medicaid; Survival
• ISSN: 2468-2942; 2468-2942
• DOI: 10.1016/j.ctarc.2020.100204

•Racial status (Non hispanic black race) was a significant predictor for therapy enrollment and mortality outcome but showed variation with respect to ACA.•For metastatic colon cancer, the impact on mortality improved post-ACA. For metastatic rectal cancer, the enrollment to therapies improved but negative impact on mortality persisted.•The Affordable Care Act appears to have had a positive impact overall but more needs to be done. Further research is warranted given limitations of the study design. Patients with advanced cancers are among the most vulnerable group of patients. We sought to analyze the impact of Affordable Care Act (ACA) on the interaction of socioeconomic factors with treatment and survival in patients with metastatic colorectal cancers. National Cancer Database (NCDB) was queried for patients with Stage-IV colon(CCa) and rectal cancers(R-Ca) diagnosed 2004–2015 and excluded those who did not receive any therapies within 6 months of diagnosis. Enrollment-rates were calculated as receipt of primary therapy as the incident-event (numerator) over time-to-initiation of therapy (denominator) and used to calculate incident-rate ratios that was analyzed using Poisson regression analysis- reported as enrollment-rate ratios (ER, <1 indicating lower enrollment rate). Multivariate Cox-proportional hazard model was performed for survival analysis and reported as calculate Hazard Ratios (HR). For CCa, enrollment to primary therapies was significantly associated (p-value < 0.05) with gender, race, insurance status, educational status and treatment facility. The HR for non-Hispanic Blacks (NHB) vs. Whites (NHW) improved from 1.1(1.03–1.11),p-value<0.005 to no-significant difference post-ACA. For R-Ca, the enrollment rates were favorable for NHB vs. NHW and ER improved from 1.15(1.0–1.32),p-value = 0.054) to 1.29(1.06–1.58),p-value = 0.013 post-ACA. Despite this, the HR for mortality were unfavorable - 1.19(1.06–1.33),p-value = 0.003 that persisted through the post-ACA period. The HR was favorable for the insured group in both cancer groups (0.84 for R-Ca,0.86 for CCa) and for high-income vs. low-income group-0.90(0.87–0.94),p-value < 0.005 in CCa. The ACA appears to have had a positive impact overall but further research and ongoing interventions are warranted to mitigate disparities in this population.