ASCO Perspective

“Everyone, everywhere should have access to the best possible care, yet, in the United States, people in minority populations continue to experience disparities in cancer treatment and survival. The findings of this study provide a solid step for closing the gap, showing that the Medicaid expansion opportunity offered by the Affordable Care Act, which allows participating states to improve healthcare access for disadvantaged populations, results in better cancer outcomes and mitigation of racial disparities in cancer survival,” said Julie R. Gralow, MD, FACP, FASCO, Chief Medical Officer and Executive Vice President of ASCO.

*Release includes data not in the abstract. DID values in the press release for 2-year mortality in patients with colorectal cancer were updated on May 25, 2023.

ALEXANDRIA, Va. — Two-year mortality and racial disparities in survival among patients with gastrointestinal (GI) cancers decreased in the time following Medicaid expansion in 2014. The research will be presented at the 2023 American Society of Clinical Oncology (ASCO) Annual Meeting.

Study at a Glance

Key Findings

Overall, Medicaid expansion was associated with a decrease in 2-year mortality for patients with GI cancers in expansion states, and an even greater reduction in mortality for Black patients residing in expansion states than for those in non-expansion states. In the study, existing racial disparities in mortality remained the same or worsened in non-expansion states but were reduced in expansion states. An increase in treatment (surgery or chemotherapy) was also seen.

“Our study provides compelling data that show Medicaid expansion was associated with improvement in survival for both Black and White patients with gastrointestinal cancers. Additionally, it suggests that Medicaid Expansion is one potential avenue to mitigate existing racial survival disparities among these patients,” said Naveen Manisundaram, MD, a research fellow at The University of Texas MD Anderson Cancer Center.

Using a difference-in-difference (DID) analysis, researchers compared the changes in 2-year mortality for Black and White patients in the time periods before Medicaid expansion (2009-13) and after expansion (2014-19) in expansion and non-expansion states. The 2-year mortality rate was adjusted for age, sex, income level, insurance status, area of residence, comorbidity index (an estimate of the risk of death from comorbid disease), and treating facility type.

Following expansion, there was a greater absolute reduction in 2-year mortality among Black patients with pancreatic cancer in expansion states (-11.8%) compared to non-expansion states (-2.4%) (DID -9.4%). In addition, in expansion states there was a greater absolute increase of treatment with chemotherapy in patients with stage 3-4 pancreatic cancer (4.5% for Black patients and 3.2% for White) compared to non-expansion states (0.8% for Black patients and 0.4% for White), (DID 3.7% for Black patients and DID 2.7% for White).

In expansion states, there was a greater absolute decrease in 2-year mortality post-expansion for patients with colorectal cancer (-4.9% for Black patients and -6% for White) compared to non-expansion states (-2% for Black patients and -1.8% for White), (DID –2.9% for Black patients and –4.2% for White). Among Black patients with stage 4 colorectal cancer, there was a net increase in rates of surgery in expansion states compared to non-expansion states (DID 5.7%), but not in treatment with chemotherapy (DID 1%, p = 0.66).

Among Black patients with stomach cancer in expansion states, post-expansion there was a greater absolute decrease in mortality in expansion states (-13%) compared to non-expansion states (-5.2%) (DID -7.7%, p = 0.07) and an absolute increase in treatment with chemotherapy among those with stage 4 stomach cancer in expansion states (8.6%) compared to an absolute decrease in non-expansion states (-2.4%) (DID 11%, p = 0.06), however, these findings were not statistically significant.

Study results were particularly notable for Black patients, for whom there was a consistent increase in receiving therapy (chemotherapy or surgery) and decrease in mortality seen across all three types of cancers (stomach, colorectal, pancreatic), resulting in the reduction of existing survival disparities between Black and White patients.

About the Study

The study included 86,052 patients from the National Cancer Database between 2009-2019 with pancreatic, colorectal, or stomach cancer. This year in the United States, an estimated 241,610 adults will be diagnosed with at least one of these cancers, and an estimated 113,470 deaths from them will occur.^1,2,3

Of the patients in the study, 22,109 (25.7%) were Black and 63,943 (74.3%) were White. Of the Black patients, 66.7% had Medicaid and 33.3% were uninsured. Of the White patients, 64.1% had Medicaid and 35.9% were uninsured.  

Medicaid coverage for more people was one of the key components of the Affordable Care Act. Medicaid is administered by the states and provides health care coverage for eligible people with disabilities or very low incomes. Many states formally adopted Medicaid expansion in January 2014; those states that participated saw large increases in Medicaid enrollment, including people with incomes near the poverty level who were newly eligible, as well as those who had been eligible but had not enrolled previously.  

Next Steps

Researchers plan to look at other types of cancers and analyze whether Medicaid Expansion had a similar effect on survival or cancer treatment.

This study was funded by the National Institutes of Health.

Addressing Health Disparities

From its inception, ASCO has been committed to addressing health disparities in cancer care and has published multiple statements and guidance to highlight specific areas of concern and efforts needed to address cancer equity, including the ASCO Equity, Diversity, and Inclusion Plan, which describes ASCO’s targets over the next 3 to 5 years in the areas of research, education, and quality of care. ASCO has also issued recommendations on reducing disparities in cancer care, reducing disparities through the Affordable Care Act, and charting the future of cancer health disparities research.

View the full abstract

View disclosures for:

• Authors – in the abstract
• ASCO Cancer Communications Committee 
• Dr. Gralow
• Dr. Winer

For your readers:

• The Affordable Care Act and Cancer
• An Expert Q/A on Cancer Disparities and Health Equity
• Resources on Cancer Disparities and Health Equity

References:

1. Colorectal Cancer: Statistics: https://www.cancer.net/cancer-types/colorectal-cancer/statistics
2. Pancreatic Cancer: Statistics: https://www.cancer.net/cancer-types/pancreatic-cancer/statistics
3. Stomach Cancer: Statistics: https://www.cancer.net/cancer-types/stomach-cancer/statistics

ATTRIBUTION TO THE AMERICAN SOCIETY OF CLINICAL ONCOLOGY ANNUAL MEETING IS REQUESTED IN ALL COVERAGE.

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