ASCO Perspectives

“Early detection and prompt treatment matters in all types of cancer, and especially in ovarian cancer. This study confirms that access to health insurance also matters and can help overcome disparities in access to care, ultimately improving long-term outcomes for patients with ovarian cancer,” said ASCO Expert Merry-Jennifer Markham, MD, FACP.

CHICAGO – An analysis of data from the National Cancer Database found that after implementation of the 2010 Affordable Care Act (ACA), ovarian cancer was diagnosed and treated at an earlier stage among women under age 65. More women also received treatment within 30 days of diagnosis, thereby increasing chances of survival.

The study will be featured in a press briefing today and presented at the 2019 American Society of Clinical Oncology (ASCO) Annual Meeting.

“Detecting and treating ovarian cancer at an early stage saves lives and lowers health care costs compared to treatment of cancer at a more advanced, incurable stage,” said lead study author Anna Jo Smith, MD, MPH, Resident in the Johns Hopkins Department of Gynecology and Obstetrics in Baltimore, MD. “Having health insurance plays a major role in whether or not a woman has access to care providers who can monitor symptoms and act on those symptoms if necessary.”

Over 75% of women diagnosed with early-stage ovarian cancer live five years or more, but the likelihood of surviving five years falls to less than 30% for women diagnosed at an advanced stage.¹ There is no screening test that can detect ovarian cancer at an early stage, and subtle symptoms can be present for years. The sooner a patient reports these symptoms to her doctor, laboratory tests can be conducted to confirm the presence of cancer, and it can then be treated as quickly as possible.

Coverage became available after the ACA was signed into law in March 2010, and by 2016-2017, nearly 12.7 million people were insured through the ACA.² The proportion of Americans who were uninsured dropped from 16% in early 2010 to less than 12% by 2016.

About the Study
The researchers examined ovarian cancer data from the National Cancer Database,³ which captures data on approximately 70% of all new ovarian cancer cases. Researchers collected data on women diagnosed and treated between 2004-2009 (pre-ACA; 35,842 patients) and 2011-2014 (post-ACA; 37,145 patients). They assessed data based on stage at ovarian cancer diagnosis and time to treatment for women age 21 to 64. The investigators compared this group with a similar sized group of women ages 65 and older. The 65 and older group was considered the control, or comparison group, as they had access to Medicare, and hence had a much lower risk of being uninsured either pre- or post-ACA.

The investigators looked at the type of insurance women had and adjusted for race, rural demographics, neighborhood household income, education level, distance traveled for care, census region, and practice setting where they received care. Researchers also adjusted the data based on the Charlson co-morbidity score, which predicts risk of death within one year of hospitalization for people with comorbid conditions.

Key Findings
The researchers used a ‘difference in differences (DD)’ approach for the analysis that compares changes over time between two groups. They calculated that, compared with women 65 and older, there was a relative gain of 1.7% in early-stage diagnosis (defined as stage 1 or 2) of ovarian cancer. There was also a relative improvement of 1.6% in women being treated within 30 days of diagnosis for those age 21 to 64 as compared with women 65 and older.

Researchers also found that women who received public insurance post-ACA saw the greatest benefits. Among publicly insured women, there were relative gains of 2.5% in early-stage diagnosis and timely treatment in those age 21 to 64 compared with women age 65 and older. All the above improvements were seen regardless of race, income, or educational level groups.

Dr. Smith noted that while a 1.7% difference in being diagnosed earlier may not sound very large, for the 22,000 women diagnosed with ovarian cancer in the United States annually, it means that close to 400 more women could be diagnosed at an early, treatable stage and have a good chance of living a longer life.

Next Steps
The researchers are now looking at the years beyond 2014 to glean additional insights, as well as correlation of ACA implementation with trends in other gynecologic cancers.

This study was funded by a Johns Hopkins Department of Gynecology and Obstetrics Kelly Society Grant.