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Background Current literature suggests that racial/ethnic minority survivors may be more likely than whites to experience economic hardship after a cancer diagnosis; however, little is known about such hardship. Methods Lung (LC) and colorectal (CRC) cancer participants of the Cancer Care Outcomes Research and Surveillance consortium (CanCORS) were surveyed approximately 4 (baseline) and 12 months (follow-up) after diagnosis. Economic hardship at follow-up was present if participants 1) indicated difficulty living on household income; and/or 2) for the following two months, anticipated experiencing hardships (inadequate housing, food, or medical attention), or reducing living standards to bare life necessities. We tested whether African Americans (AAs) and Hispanics were more likely than whites to experience economic hardship controlling for gender, age, education, marital status, cancer stage, treatment, and economic status at baseline (income, prescription drug coverage). Results Of 3,432 survivors (39.7% LC, 60.3% CRC) 14.0% were AA, 7% Hispanic and 79% white. AAs and Hispanics had lower education and income than whites. About 68% AAs, 58% Hispanics, and 44.5% whites reported economic hardship. In LC participants, the Hispanic-white disparity was not significant in unadjusted or adjusted analyses, the AA-white disparity was explained by baseline economic status. In CRC participants, the Hispanic-white disparity was explained by baseline economic status, the AA-white disparity was not explained by variables included in the model, Conclusions Economic hardship was evident in almost 1 in 2 cancer survivors one year after diagnosis, especially AAs. Research should evaluate and address risk factors and impact on survival and survivorship outcomes.

Background The Community Health Advisor (CHA) model has been widely used to recruit rural and low-income, mostly African American women into clinical and behavioral research studies. However, little is known about its effectiveness in promoting retention and adherence of such women in clinical trials. Methods The Community-based Retention Intervention Study (CRIS) evaluated the effectiveness of a community-based intervention strategy using the CHA model and the empowerment theory to improve the retention and adherence of minority and low-income women in clinical trials. The research strategy included the training and use of the volunteer CHAs as research partners. The target population included women participating in the University of Alabama at Birmingham (UAB) clinical site of the ASCUS-LSIL Triage Study (ALTS), a multicenter, randomized clinical trial. Two communities in Jefferson County, Alabama, matched according to population demographics, were identified and randomly assigned to either intervention or control group. Thirty community volunteers were recruited to be CHAs and to implement the intervention with the ALTS trial participants. A total of 632 ALTS participants agreed to participate in the project: 359 in the intervention group with CHA care, and 273 in the control group with standard care. Results Adherence rates for scheduled clinic visits were significantly higher in the intervention group (80%) compared to the control group (65%; p < 0.0001). Conclusion Results indicate that volunteer CHAs can be trained to serve as research partners and be effective in improving the retention and adherence of minority and low-income women in clinical trials.

Background The number of Medicaid beneficiaries has increased under the Affordable Care Act (ACA), improving access to solid organ transplantation in this disadvantaged patient cohort. It is unclear what impact Medicaid expansion will have on transplant outcomes. We performed a retrospective cohort analysis to measure the frequency and variation in Medicaid transplantation, and post-transplant survival in Medicaid patients. Study Design Adult heart, lung, liver, and renal transplant recipients between 2002 and 2011 (n=169,194) reported to the Scientific Registry of Transplant Recipients were identified. Transplant recipients were classified based on insurance status (Private, Medicare or Medicaid). Outcome measures included five-year post-transplant survival, summarized using Kaplan-Meier curves and compared with log-rank tests. Organ-specific Cox proportional hazards models were used to adjust for donor and recipient factors. Results Medicaid patients comprised 8.6% of all organ transplant recipients. Fewer transplants were performed than expected among Medicaid beneficiaries for all organs but liver [Observed/Expected ratios (95% CI): liver=1.21 (0.68, 1.90); heart=0.89 (0.44, 1.49); lung=0.57 (0.22, 1.06); renal=0.32 (0.08, 0.72)]. Medicaid transplant recipients were listed with more severe organ failure and experienced shorter transplant wait times. Post-transplant survival was lower in Medicaid patients compared to Private insurance for all organs. Post-transplant survival in Medicaid patients was similar to Medicare patients for heart, liver and renal but lower in lung. Conclusions Medicaid organ transplant beneficiaries had significantly lower survival compared to Privately insured beneficiaries. The more severe organ failure among Medicaid beneficiaries at the time of listing suggested a pattern of late referral, which may account for worse outcomes. Implementation of the ACA affords the opportunity to develop the necessary infrastructure to ensure timely transplant referrals and improve long-term outcomes in this vulnerable population.

Changes to the liver allocation system have been proposed to decrease regional variation in access to liver transplant. It is unclear what impact these changes will have on cold ischemia times (CITs) and donor transportation costs. Therefore, we performed a retrospective single center study (2008–2012) measuring liver procurement CIT and transportation costs. Four groups were defined: Local-within driving distance (Local-D, n = 262), Local-flight (Local-F, n = 105), Regional-flight <3 h (Regional <3h, n = 61) and Regional-Flight >3 h (Regional >3h, n = 53). The median travel distance increased in each group, varying from zero miles (Local-D), 196 miles (Local-F), 384 miles (Regional <3 h), to 1647 miles (Regional >3 h). Increasing travel distances did not significantly increase CIT until the flight time was >3 h. The average CIT ranged from 5.0 to 6.0 h for Local-D, Local-F and Regional <3h, but increased to 10 h for Regional >3h (p < 0.0001). Transportation costs increased with greater distance traveled: Local-D $101, Local-F $1993, Regional <3h $8324 and Regional >3 h $27 810 (p < 0.0001). With proposed redistricting, local financial modeling suggests that the average liver donor procurement transportation variable direct costs will increase from $2415 to $7547/liver donor, an increase of 313%. These findings suggest that further discussion among transplant centers and insurance providers is needed prior to policy implementation.