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Although Affordable Care Act (ACA) implementation has improved cancer outcomes, less is known about how much the improvement applies to different racial and ethnic populations. We examined changes in health insurance coverage and cancer-specific mortality rates by race/ethnicity pre- and post-ACA. We identified newly diagnosed breast (n = 117,738), colorectal (n = 38,334), and cervical cancer (n = 11,109) patients < 65 years in California 2007-2017. Hazard rate ratios (HRR) and 95% confidence intervals (CI) were calculated using multivariable Cox regression to estimate risk of cancer-specific death pre- (2007-2010) and post-ACA (2014-2017) and by race/ethnicity [American Indian/Alaska Natives (AIAN); Asian American; Hispanic; Native Hawaiian or Pacific Islander (NHPI); non-Hispanic Black (NHB); non-Hispanic white (NHW)]. Cancer-specific mortality from colorectal cancer was lower post-ACA among Hispanic (HRR = 0.82, 95% CI = 0.74 to 0.92), NHB (HRR = 0.69, 95% CI = 0.58 to 0.82), and NHW (HRR = 0.90; 95% CI = 0.84 to 0.97) but not Asian American (HRR = 0.95, 95% CI = 0.82 to 1.10) patients. We observed a lower risk of death from cervical cancer post-ACA among NHB women (HRR = 0.68, 95% CI = 0.47 to 0.99). No statistically significant differences in breast cancer-specific mortality were observed for any racial or ethnic group. Cancer-specific mortality decreased following ACA implementation for colorectal and cervical cancers for some racial and ethnic groups in California, suggesting Medicaid expansion is associated with reductions in health inequity.

Historically, lower socioeconomic status (SES) has been reported to be associated with decreased breast cancer incidence and mortality and increased case-fatality, although recent trends in breast cancer screening and treatment may alter these relationships. This study assessed the associations between SES and breast cancer incidence, case-fatality, and mortality by stage of disease at diagnosis using recent data in the United States. Breast cancer incidence and survival data from the Surveillance, Epidemiology, and End Results (SEER) tumor registry for black and white women aged 55 and above were linked to county level SES and population data based on place of residence. Poisson regression was used to calculate age-adjusted relative rates associated with SES levels and breast cancer incidence, case-fatality, and mortality. As SES decreased, localized breast cancer incidence rates decreased, while incidence rates of distant disease increased. Five-year localized and regional breast cancer case-fatality rates increased as SES decreased. Localized breast cancer mortality rates decreased as SES declined, whereas regional breast cancer mortality rates tended to increase. These results confirm some previously reported findings and suggest that associations between lower SES and lower localized breast cancer mortality rates are influenced mainly by underlying associations between SES and localized breast cancer incidence, whereas regional breast cancer mortality rates appear to reflect the underlying association between SES and regional case-fatality rates. Keywords: Socioeconomic factors; Breast neoplasms; Incidence; Mortality; Survival; Case-fatality

Purpose: The purpose of this paper is to provide a brief overview of economic analysis methods used in estimating the costs and benefits of public health programs and systematically review the application of these methods to the National Breast and Cervical Cancer Early Detection Program (NBCCEDP).Methods: Published literature on economic analyses of the NBCCEDP was systematically reviewed. The Consensus on Health Economic Criteria checklist was used to assess methodological quality of the included studies.Results: Methods available for economic analysis of public health programs include program cost, cost-effectiveness, cost-utility, cost-benefit analysis, and budget impact analysis. Of these, program cost analysis, cost-effectiveness analysis, and cost-utility analysis have been applied to the NBCCEDP in previously published literature.Conclusion: While there have been multiple program cost analyses, there are relatively fewer cost-effectiveness and cost-utility studies and no cost-benefit and budget impact analysis studies to evaluate the NBCCEDP. Addressing these gaps will inform implementation of effective public health programs with equitable resource allocation to all population subgroups. [ABSTRACT FROM AUTHOR]

Introduction: Medicaid expansions following the Affordable Care Act have improved insurance coverage in low-income adults, but little is known about its impact on cancer screening. This study examined associations between Medicaid expansion timing and colorectal cancer (CRC) and breast cancer (BC) screening.Methods: Up-to-date and past 2-year CRC (n=95,400) and BC (women, n=43,279) screening prevalence were computed among low-income respondents aged 50-64 years in 2012, 2014, and 2016 Behavioral Risk Factor Surveillance System data. Respondents were grouped according to Medicaid expansion timing as: very early ([VE] six states expanding March 1, 2010-April 14, 2011), early (21 states expanding January 1, 2014-August 15, 2014), late (five states expanding January 1, 2015-July 1, 2016), and non-expansion states (19 states). Absolute adjusted difference-in-differences (aDDs) were computed in 2018-2019 (ref, non-expansion states).Results: Between 2012 and 2016, absolute up-to-date CRC screening increased by 8.8%, 2.9%, 2.4%, and 3.8% among low-income adults in VE, early, late, and non-expansion states, respectively. Past 2-year CRC screening increased by 8.0% in VE and 2.8% in non-expansion states, with an aDD of 4.9% (p=0.041). In 2012-2016, up-to-date BC screening increased by 5.1%, 4.9%, and 3.7% among low-income women in VE, early, and non-expansion states, respectively, but aDDs were not statistically significant.Conclusions: Prevalence of CRC and BC screening among low-income adults rose in Medicaid expansion states, though increases were significantly higher than those in non-expansion states only for recent CRC screening in VE expansion states. Large-scale improvements in cancer screening may take several years following expansion in access to care. [ABSTRACT FROM AUTHOR]

Introduction: There is increasing concern regarding the financial burden of cancer on patients and their families. This study presents nationally representative estimates of annual out-of-pocket (OOP) burden among non-elderly cancer survivors and assesses the association between high OOP burden and access to care and preventive service utilization.Methods: Using the 2008-2012 Medical Expenditure Panel Survey, 4,271 cancer survivors and 96,780 individuals without a history of cancer were identified, all aged 18-64 years. High annual OOP burden was defined as spending >20% of annual family income on OOP healthcare costs. Associations between high OOP burden and access to care were evaluated with multivariable logistic regression. Analyses were conducted in 2015.Results: Compared with individuals without a cancer history, cancer survivors were more likely to report a high OOP burden (4.3% vs 3.4%, p=0.009) in adjusted analyses. High OOP burden was more common among cancer survivors who were poor (18.4%), with either public insurance (7.9%) or uninsured (5.7%), and not working (10.2%). Among cancer survivors, high OOP burden was associated with being unable to obtain necessary medical care (19.2% vs 12.5%, p=0.002), delaying necessary medical care (21.6% vs 13.8%, p=0.002), and lower breast cancer screening rates among age-appropriate women (63.2% vs 75.9%, p=0.02).Conclusions: High OOP burden is more common among adults with a cancer history than those without a cancer history. High OOP burden was associated with being unable to obtain necessary medical care, delaying necessary medical care, and lower breast cancer screening rates among women. [ABSTRACT FROM AUTHOR]

Background Current estimates of the costs of cancer care in the United States are based on data from 2003 and earlier. However, incidence, survival, and practice patterns have been changing for the majority of cancers. Methods Cancer prevalence was estimated and projected by phase of care (initial year following diagnosis, continuing, and last year of life) and tumor site for 13 cancers in men and 16 cancers in women through 2020. Cancer prevalence was calculated from cancer incidence and survival models estimated from Surveillance, Epidemiology, and End Results (SEER) Program data. Annualized net costs were estimated from recent SEER–Medicare linkage data, which included claims through 2006 among beneficiaries aged 65 years and older with a cancer diagnosis. Control subjects without cancer were identified from a 5% random sample of all Medicare beneficiaries residing in the SEER areas to adjust for expenditures not related to cancer. All cost estimates were adjusted to 2010 dollars. Different scenarios for assumptions about future trends in incidence, survival, and cost were assessed with sensitivity analysis. Results Assuming constant incidence, survival, and cost, we projected 13.8 and 18.1 million cancer survivors in 2010 and 2020, respectively, with associated costs of cancer care of 124.57 and 157.77 billion 2010 US dollars. This 27% increase in medical costs reflects US population changes only. The largest increases were in the continuing phase of care for prostate cancer (42%) and female breast cancer (32%). Projections of current trends in incidence (declining) and survival (increasing) had small effects on 2020 estimates. However, if costs of care increase annually by 2% in the initial and last year of life phases of care, the total cost in 2020 is projected to be $173 billion, which represents a 39% increase from 2010. Conclusions The national cost of cancer care is substantial and expected to increase because of population changes alone. Our findings have implications for policy makers in planning and allocation of resources. [ABSTRACT FROM PUBLISHER]

The article discusses a study which explored whether detection by mammography was associated with greater use of guideline-consistent breast cancer treatment among patients with diagnosed breast cancer in the U.S. The study found that patients who were diagnosed by mammography were more to have lower stage disease and to be treated in larger hospitals than patients who were diagnosed by other methods. It concluded that survival among patients with diagnosed breast cancer may inform understanding of factors associated with breast cancer prognosis.

Background: Although recent trends in the use of recommended breast and cervical cancer screening have been well documented in the USA, little is known about trends in the prevalence of abnormal screening results. Methods: Trends in abnormal screening results for mammography and Papanicolaou (Pap) smear were assessed descriptively using data from the 1987 and 2000 National Health Interview Surveys. Estimates were stratified by sociodemographic characteristics of the populations who reported ever receiving screening. All comparisons were evaluated with two-sided tests of statistical significance. Results: The age-standardized prevalence of abnormal Pap smears increased from 12.9% (95% confidence interval [CI] 12.1–13.8%) of women ever screened in 1987 to 20.3% (95% CI 19.5–21.0%) in 2000, and the age-standardized prevalence of abnormal mammogram results increased from 18.8% (95% CI 17.0–20.7%) to 21.6% (95% CI 20.5–22.7%) of women ever screened over the same period. Among women aged 40 years and older who reported ever receiving both a Pap smear and a mammogram, 29.6% (95% CI: 27.3–32.2%) in 1987 and 35% (95% CI: 33.8–36.2%) in 2000 reported either an abnormal Pap smear or an abnormal mammogram. In 2000, abnormal screening results were positively associated with reported frequency of recent screening (P<0.001). Conclusions: A substantial portion of women in the USA reporting cancer screening also report having had abnormal results, although the magnitude of trends between 1987 and 2000 vary by screening test. Additional research is needed to assess the relative contributions of changes in classification of test results, test characteristics and changes in underlying screening histories to increases in abnormal screening results. [ABSTRACT FROM AUTHOR]

Abstract: Background: None of the recent national studies has ascertained how women''s breast cancer was detected in the United States. To rectify this gap, questions were added to the leading national health survey. Mammography was of special interest because it is widely used in the US and has evidence of a mortality benefit. Methods: We used the 2003 National Health Interview Survey (NHIS), to ascertain the self-reported modalities used to detect breast cancer in the non-institutionalized US population. The study included 345 women 40–84 years of age who, in 2003, reported a personal history of breast cancer. We examined the frequency of self-reported characteristics and tested for association with mammography-detected breast cancer using logistic regression. Results: Among the survivors in 2003, the percentage of breast cancers detected by mammography was much higher after 2001 (59%) than before 1993 (29%). Breast cancer survivors with less than high school education or less than US$ 20,000 household income were less likely to report detection by mammography. Conclusions: Women reported mammography-detected breast cancer at a slightly higher rate than published studies of mammography sensitivity and use would suggest. Lower rates of mammography-detected breast cancers among survivors with low income or low education raise the question whether mammography is underutilized as a diagnostic tool, especially for underserved women. [Copyright &y& Elsevier]

Context: Optimal ages of breast cancer screening cessation remain uncertain.Objective: To evaluate screening policies based on age and quartiles of life expectancy (LE).Design and Population: We used a stochastic model with proxies of age-dependent biology to evaluate the incremental U.S. societal costs and benefits of biennial screening from age 50 until age 70, 79, or lifetime.Main Outcome Measures: Discounted incremental costs per life years saved (LYS).Results: Lifetime screening is expensive (151,434 dollars per LYS) if women have treatment and survival comparable to clinical trials (idealized); stopping at age 79 costs 82,063 dollars per LYS. This latter result corresponds to costs associated with an LE of 9.5 years at age 79, a value expected for 75% of 79-year-olds, about 50% of 80-year-olds, and 25% of 85-year-olds. Using actual treatment and survival patterns, screening benefits are greater, and lifetime screening of all women might be considered (114,905 dollars per LYS), especially for women in the top 25% of LE for their age (50,643 dollars per LYS, life expectancy of approximately 7 years at age 90).Conclusions: If all women receive idealized treatment, the benefits of mammography beyond age 79 are too low relative to their costs to justify continued screening. However, if treatment is not ideal, extending screening beyond age 79 could be considered, especially for women in the top 25% of life expectancy for their age. [ABSTRACT FROM AUTHOR]

Looks at variations in surgical techniques for early-stage breast cancer. Review of how, starting in the early 1980s, randomized trials reported equivalent survival in patients with early-stage breast cancer receiving breast-conserving surgery and radiotherapy or modified radical mastectomy; Overview of a study conducted by L. Caldon and colleagues on mastectomy rates in over five-thousand women with breast cancer; Analysis of the results of the study, which found that surgeons characteristics such as specialty, gender, years of experience, as well as patient characteristics influenced variations in breast cancer surgery.

Background Little is known about patterns of and factors associated with treatment for de novo metastatic cancer patients who die soon after diagnosis. In this study, we examine treatment patterns for patients newly diagnosed with metastatic lung, colorectal, breast, or pancreatic cancer who died within 1 month of diagnosis. Methods We identified 100 848 adult patients in the National Cancer Database with de novo metastatic lung, colorectal, breast, and pancreatic cancer, diagnosed between 2004 and 2014 and who died within 1 month. We performed descriptive and multivariable logistic regression analyses to examine receipt of surgery, chemotherapy, radiation, and hormonal therapy by cancer type, adjusting for sociodemographic and clinical variables. Results Treatment substantially varied by cancer type, over time, age, insurance, and facility type. Surgery ranged from 0.4% in pancreatic to 28.3% in colorectal cancer (CRC) patients, chemotherapy from 5.8% among CRC to 11% in lung and breast cancer patients, and radiotherapy from 1.3% in pancreatic to 18.7% in lung cancer patients. Use of some treatments (eg, surgery for CRC and breast cancer) progressively declined between 2004 and 2014. Compared with lung cancer patients treated at National Cancer Institute-designated cancer centers, those treated at community cancer centers had 48% lower odds of radiation. Conclusions Treatment of patients diagnosed with imminently fatal de novo metastatic cancer varied markedly by cancer type and patient/facility characteristics. These variations warrant more research to better identify patients with imminently fatal de novo metastatic cancer who may not benefit from aggressive and expensive therapies. [ABSTRACT FROM AUTHOR]

: BackgroundThe purpose of this study was to examine trends in the use of clinical breast examinations (CBE), mammography, and both tests between the years 1990 and 2000.: MethodsReceipt of breast cancer screening tests (CBE, mammography, and both tests combined) for white, black, and Hispanic women in 1990, 1994, 1998, and 2000 were examined by sociodemographic, access, and health risk indicators using data from the National Health Interview Survey.: ResultsThe use of mammography increased from 1990 to 2000, but the proportion of women reporting a recent CBE decreased for almost all groups of women. Differential use of CBE by sociodemographic characteristics is consistent with what has been documented for mammography.: ConclusionsAlthough the use of mammography has increased since 1990, there has been a downward trend in the use of CBE. Healthcare providers should be aware of the lower rates of CBE, particularly among women with compromised access to health care, and should not assume that women who get mammograms have received comprehensive screening for breast cancer. [Copyright &y& Elsevier]