Lack of health insurance coverage is strongly associated with poor cancer outcomes in the United States. The uninsured are less likely to have access to timely and effective cancer prevention, screening, diagnosis, treatment, survivorship, and end-of-life care than their counterparts with health insurance coverage. On March 23, 2010, the Patient Protection and Affordable Care Act (ACA) was signed into law, representing the largest change to health care delivery in the United States since the introduction of the Medicare and Medicaid programs in 1965. The primary goals of the ACA are to improve health insurance coverage, the quality of care, and patient outcomes, and to maintain or lower costs by catalyzing changes in the health care delivery system. In this review, we describe the main components of the ACA, including health insurance expansions, coverage reforms, and delivery system reforms, provisions within these components, and their relevance to cancer screening and early detection, care, and outcomes. We then highlight selected, well-designed studies examining the effects of the ACA provisions on coverage, access to cancer care, and disparities throughout the cancer control continuum. Finally, we identify research gaps to inform evaluation of current and emerging health policies related to cancer outcomes. CA Cancer J Clin 2020;70:165-181.
Background Transgender persons face many barriers to healthcare that may delay cancer diagnosis and treatment, possibly resulting in decreased survival. Yet, data on cancer in this population are limited. We examined cancer stage at diagnosis, treatment, and survival among transgender patients compared to cisgender patients in the National Cancer Database (NCDB). Methods Gender (male, female, or transgender) was extracted from medical records from patients diagnosed with cancer between 2003–2016. Logistic regression estimated odds ratios (ORs) for the associations between gender and stage at diagnosis and treatment receipt. Cox proportional hazards regression estimated hazard ratios (HRs) for associations between gender and all-cause survival. Results Among 11,776,699 persons with cancer in NCDB, 589 were transgender. Compared to cisgender patients, transgender patients may be more likely to be diagnosed with advanced stage lung cancer (OR = 1.76, 95% confidence interval [CI]= 0.95, 3.28), less likely to receive treatment for kidney (OR = 0.19, 95%CI= 0.08, 0.47) and pancreas (OR = 0.33, 95%CI= 0.11, 0.95) cancers, and have poorer survival after diagnosis with non-Hodgkin lymphoma (HR = 2.34; 95%CI= 1.51, 3.63), prostate (HR = 1.91, 95%CI= 1.06, 3.45), and bladder cancers (HR = 2.86, 95%CI= 1.36, 6.00). Similar associations were found for other cancer sites, though not statistically significant. Conclusion Transgender patients may be diagnosed at later stages, be less likely to receive treatment, and have worse survival for many cancer types. Small sample size hampered our ability to detect statistically significant differences for some cancer sites. There is a need for transgender-focused cancer research as the population ages and grows.
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