In pursuit of equity in cancer care: Moving beyond the Affordable Care Act

Dee, Edward Christopher; Pierce, Lori J.; Winkfield, Karen M.; Lam, Miranda

doi:10.1002/cncr.34346

Cited by 12 publications

(8 citation statements)

References 86 publications

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“…[39][40][41][42][43][44][45] The structural racism that Black patients face across healthcare settings perpetuates the disparate access and outcomes. 12,46,47 We show that timely access to definitive prostate cancer treatment remains a disproportionate albeit narrowing challenge for non-White men even in the years after the ACA was implemented.…”

Section: Discussionmentioning

confidence: 89%

“…Beyond the standard of care, non‐White men are significantly underrepresented on clinical trials and have lower utilization of advanced radiotherapy techniques such as proton therapy 39–45 . The structural racism that Black patients face across healthcare settings perpetuates the disparate access and outcomes 12,46,47 . We show that timely access to definitive prostate cancer treatment remains a disproportionate albeit narrowing challenge for non‐White men even in the years after the ACA was implemented.…”

Section: Discussionmentioning

confidence: 90%

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Disparities in time to prostate cancer treatment initiation before and after the Affordable Care Act

et al. 2023

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BackgroundDelayed access to care may contribute to disparities in prostate cancer (PCa). The Affordable Care Act (ACA) aimed at increasing access and reducing healthcare disparities, but its impact on timely treatment initiation for PCa men is unknown.MethodsMen with intermediate‐ and high‐risk PCa diagnosed 2010–2016 and treated with curative surgery or radiotherapy were identified in the National Cancer Database. Multivariable logistic regression modeled the effect of race and insurance type on treatment delay >180 days after diagnosis. Cochran–Armitage test measured annual trends in delays, and joinpoint regression assessed if 2014, the year the ACA became fully operationalized, was significant for inflection in crude rates of major delays.ResultsOf 422,506 eligible men, 18,720 (4.4%) experienced >180‐day delay in treatment initiation. Compared to White patients, Black (OR 1.79, 95% CI 1.72–1.87, p < 0.001) and Hispanic (OR 1.37, 95% CI 1.28–1.48, p < 0.001) patients had higher odds of delay. Compared to uninsured, those with Medicaid had no difference in odds of delay (OR 0.94, 95% CI 0.84–1.06, p = 0.31), while those with private insurance (OR 0.57, 95% CI 0.52–0.63, p < 0.001) or Medicare (OR 0.64, 95% CI 0.58–0.70, p < 0.001) had lower odds of delay. Mean time to treatment significantly increased from 2010 to 2016 across all racial/ethnic groups (trend p < 0.001); 2014 was associated with a significant inflection for increase in rates of major delays.ConclusionsNon‐White and Medicaid‐insured men with localized PCa are at risk of treatment delays in the United States. Treatment delays have been consistently rising, particularly after implementation of the ACA.

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Section: Discussionmentioning

confidence: 89%

Section: Discussionmentioning

confidence: 90%

Disparities in time to prostate cancer treatment initiation before and after the Affordable Care Act

et al. 2023

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“…These structural barriers are broad, ranging from disproportionately lower socioeconomic status and high rates of uninsurance owing to historical and present injustices inflicted on minoritized groups and subsequent mistrust of the medical system. 26,27,36 Although it could be argued that part of the disparity in access to shorter radiation courses could be attributed to greater risk of presenting with more advanced disease among minoritized groups, 25,37,38 such an explanation further reflects inequities that persist at each point in the cancer spectrum, ranging from suboptimal screening to delays in treatment initiation. [23][24][25]27,37,38 Indeed, Black communities shoulder the highest cancer mortality burden from BC and PC in the United States, with recent survival estimates 8%-20% lower than other groups.…”

Section: Discussionmentioning

confidence: 99%

“…[17][18][19][20][21] Despite these advances in radiotherapy techniques, inequities in their utilization and subsequent disparities in oncologic outcomes persist for Black versus non-Black patients with BC and PC in the United States. [22][23][24][25][26] This is attributable in part to systemic bias and barriers in access to care. 27 One important potential benefit of shorter fractionation schemes is an improvement in treatment completion rates among patients receiving radiation therapy (RT).…”

Section: Corresponding Author Introductionmentioning

confidence: 99%

Shorter Radiation Regimens and Treatment Noncompletion Among Patients With Breast and Prostate Cancer in the United States: An Analysis of Racial Disparities in Access and Quality

Dee

Taunk

Chino

et al. 2023

JCO Oncology Practice

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PURPOSE: Compared with conventional external-beam radiation therapy (cEBRT) for patients with breast cancer (BC) and prostate cancer (PC), shorter radiation regimens may be associated with lower treatment noncompletion rates. We assess disparities in receipt of shorter radiation regimens and treatment noncompletion for BC and PC. PATIENTS AND METHODS: The 2004-2017 National Cancer Database was queried for adjuvant cEBRT or hypofractionated EBRT (hEBRT) for nonmetastatic BC; and definitive cEBRT, moderate hypofractionation (mEBRT), or stereotactic body radiotherapy (SBRT) for localized PC. Multivariable logistic regression identified factors associated with treatment noncompletion and receipt of shorter regimens. FINDINGS: We identified 170,386 men with PC (median age [interquartile range], 70 [64-75] years; Black, 17.5%; White, 82.5%) and 306,846 women with BC (61 [52-69] years; Black, 12.3%; White, 87.7%). Among patients who received cEBRT for PC, Black men had higher treatment noncompletion rates compared with White (14.1% v 13.0%; odds ratio [95% CI] 1.07 [1.03 to 1.12]; P < .001). In contrast, treatment noncompletion was not disparate with SBRT (Black 1.6% v White 1.3%; 1.20 [0.72 to 2.00], P = .49) or mEBRT (Black 9.0% v White 7.1%; 1.05 [0.72 to 1.54], P = .79). From 2004 to 2017, SBRT (0.07% to 11.8%; 1.32 [1.31 to 1.33]) and mEBRT (0.35% to 9.1%; 1.27 [1.25 to 1.28]) increased (both P < .001); however, Black men were consistently less likely to receive SBRT (7.4% v White, 8.3%; 0.84 [0.79 to 0.89], P < .001). Among women with BC, there were no racial differences in treatment noncompletion; however, hEBRT was associated with lower treatment noncompletion rates (1.0% v cEBRT 2.3%; 0.39 [0.35 to 0.44], P < .001). Although hEBRT for BC increased (0.8% to 35.6%) between 2004 and 2017, Black women were less likely to receive hEBRT (10.4% v 15.3%; 0.78 [0.75 to 0.81], P < .001). INTERPRETATION: Black patients were consistently less likely to receive hypofractionated radiation for PC or BC, despite evidence suggesting that shorter regimens may lower rates of treatment noncompletion with similar oncologic outcomes.

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“…Other authors have noted similar disappointing results. 3 The authors state that there must be systemic factors that are influencing the outcomes such as selection bias, referral rates, or other more complex socioeconomic factors. Since the NCDB is hospital based, rather than population based, it is even possible that the more affluent and mobile patients seek postoperative care in nonparticipating states while the geographically and economically confined patients return to their home institution.…”

mentioning

confidence: 99%