Breast cancer patients' insurance status and residence zip code correlate with early discontinuation of endocrine therapy: An analysis of the ECOG‐ACRIN TAILORx trial

Abstract

Background Early discontinuation is a substantial barrier to the delivery of endocrine therapies (ETs) and may influence recurrence and survival. The authors investigated the association between early discontinuation of ET and social determinants of health, including insurance coverage and the neighborhood deprivation index (NDI), which was measured on the basis of patients' zip codes, in breast cancer. Methods In this retrospective analysis of a prospective randomized clinical trial (Trial Assigning Individualized Options for Treatment), women with hormone receptor–positive, human epidermal growth factor receptor 2–negative breast cancer who started ET within a year of study entry were included. Early discontinuation was calculated as stopping ET within 4 years of its start for reasons other than distant recurrence or death via Kaplan‐Meier estimates. A Cox proportional hazards joint model was used to analyze the association between early discontinuation of ET and factors such as the study‐entry insurance and NDI, with adjustments made for other variables. Results Of the included 9475 women (mean age, 55.6 years; White race, 84%), 58.0% had private insurance, whereas 11.7% had Medicare, 5.8% had Medicaid, 3.8% were self‐pay, and 19.1% were treated at international sites. The early discontinuation rate was 12.3%. Compared with those with private insurance, patients with Medicaid (hazard ratio [HR], 1.53; 95% confidence interval [CI], 1.23‐1.92) and self‐pay patients (HR, 1.65; 95% CI, 1.25‐2.17) had higher early discontinuation. Participants with a first‐quartile NDI (highest deprivation) had a higher probability of discontinuation than those with a fourth‐quartile NDI (lowest deprivation; HR, 1.34; 95% CI, 1.11‐1.62). Conclusions Patients' insurance and zip code at study entry play roles in adherence to ET, with uninsured and underinsured patients having a high rate of treatment nonadherence. Early identification of patients at risk may improve adherence to therapy. Lay Summary In this retrospective analysis of 9475 women with breast cancer participating in a clinical trial (Trial Assigning Individualized Options for Treatment), Medicaid and self‐pay patients (compared with those with private insurance) and those in the highest quartile of neighborhood deprivation scores (compared with those in the lowest quartile) had a higher probability of early discontinuation of endocrine therapy. These social determinants of health assume larger importance with the expected increase in unemployment rates and loss of insurance coverage in the aftermath of the coronavirus disease 2019 pandemic. Early identification of patients at risk and enrollment in insurance optimization programs may improve the persistence of therapy.

Breast Cancer Statistics, 2022

“…A more recent study found that racial/ethnic disparities in stage IV breast cancer survival were mitigated in areas where Medicaid expansion increased access to care 103 . Studies have also shown that Black women are more likely than White women to experience treatment delay and discontinuation and are less likely to receive guideline‐concordant care, even after controlling for insurance status 104–108 . Efforts to improve survival outcomes among Black women and other underserved populations require multifaceted interventions to address systemic inequalities across the continuum of breast cancer care.…”

The avoidable casualties in America's war on cancer

“…This study by Sadigh et al 1 demonstrates yet again the powerful association between poverty, inadequacy of treatment coverage, and the receipt of poor care and even treatment abandonment. It is an example of the high price paid because of the lack of universal health coverage and social supports to provide adequate health care.…”

“…Sadigh et al 1 studied patients with breast cancer in the landmark Trial Assigning Individualized Options for Treatment (TAILORx) study and found that social determinants such as a patient's insurance status and neighborhood deprivation index correlate with the patient's adherence to long‐term hormonal therapy. Medicaid and self‐pay patients and patients from the poorest neighborhoods were most likely to discontinue hormonal therapy 1,2 …”

“…The 31% decline in the age‐adjusted cancer death rate from 1991 to 2018 is largely due to the application of findings from research funded through the war on cancer 4 . It is ironic that Sadigh et al 1 provide research showing that lives are lost simply because Americans drop out of effective therapy on account of the inability to afford the fruits of research gained from that war.…”

“…To some, it is obvious that a lack of health insurance or poor health insurance leads to receipt of “less than optimal” care; others need data. Sadigh et al 1 provide that data in an analysis of participant adherence in a clinical trial that demonstrated the utility of gene expression profiling. Indeed, low‐stage, hormone receptor–positive, human epidermal growth factor receptor 2–negative breast cancer is one of the most treatable forms of the disease.…”