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ASCO Preview: Cancer Deaths Down in Medicaid Expansion States
— Plus: Integrative oncogeriatric care boosts QOL in elderly cancer patients
by Ian Ingram, Deputy Managing Editor, MedPage Today May 13, 2020
Medicaid expansion under the Affordable Care Act (ACA) was associated with reduced mortality rates among cancer patients, a large retrospective analysis found.
Comparing deaths from cancer in 2011-2013 versus 2015-2017, which captures the time pre- and post-ACA implementation, revealed a significant reduction in cancer mortality among states that expanded access to the low-income insurance program (-1.1 per 100,000; P=0.006), but not in non-expansion states (-0.6 per 100,000; P=0.134), reported Anna Lee, MD, MPH, of Memorial Sloan Kettering Cancer Center in New York City.
"Cancer mortality decreased over time across all populations, with additional benefit in states that expanded Medicaid for 2014," said Lee during a press briefing ahead of the American Society of Clinical Oncology (ASCO) annual meeting.
The survival gains in expansion states translated to roughly 785 fewer cancer deaths in 2017, Lee noted, and an estimated 589 additional cancer deaths could have been prevented if all states had participated in the expansion.
"Hispanic populations seemed to reap the most benefit with the greatest additional mortality decrease," said Lee. "Black patients did not appear to reap the same mortality decrease, although this may be due to continued large mortality gains over time."
Hispanic patients saw a reduction of 2.0 cancer deaths per 100,000 people in expansion states (P=0.008) but no change in non-expansion states. Similarly, white patients saw a reduction of 1.3 cancer deaths per 100,000 (P=0.001) in expansion states but no significant change in non-expansion states.
For their study, Lee's group used a CDC database to capture all cancer-related deaths in the U.S. In all, 27 states plus the District of Columbia chose to participate in the ACA Medicaid expansion by the start of 2015, while the remaining 23 states did not. Difference-in-differences analyses showed no significant difference between expansion and non-expansion states but mortality declines favored expansion states overall, and especially among Hispanic and white populations.
Lee noted that from 1999 to 2017, age-adjusted deaths from cancer have dropped significantly overall, from 66.9 to 48.8 per 100,000 individuals. Among expansion states, deaths during this 18-year period dropped from 65.1 to 46.3 per 100,000, while in non-expansion states deaths fell from 69.5 to 52.3 per 100,000 (P<0.001 for all).
Integrative Oncogeriatric Care Boosts QOL
Including a geriatric assessment and integrating a geriatrician into the patient management improved quality of life (QOL) measures for older patients undergoing anti-cancer treatment, a researcher reported.
Among over 150 elderly patients receiving chemotherapy, targeted agents, or immunotherapy, those randomized to the integrated oncogeriatric care program had significantly improved scores on the Elderly Functional Index (ELFI) at 12, 18, and 24 weeks compared with those assigned to usual care, reported Wee-Kheng Soo, MBBS, of Eastern Health and Monash University in Melbourne, Australia.
"INTEGRATE is the first randomized controlled trial to show the effectiveness of integrative oncogeriatric care," Soo said during the ASCO briefing.
From 2014 to 2018, INTEGRATE assigned 76 patients age 70 and older with various solid tumors or diffuse large B-cell lymphoma to the integrated oncogeriatric care program and 78 to usual care. Average scores on the 100-point ELFI scale, where higher scores indicate better QOL, favored the intervention group at all time points measured:
12 weeks: 71.4 vs 60.3 (P=0.004)
Patients exposed to the intervention also had reductions in emergency room use (39%), unplanned admissions (43%), and overnight stays at hospitals (24%). And these patients were more likely to stay on treatment, with only 32.9% stopping treatment for toxicity versus 53.2% in the usual care group.
"These findings suggest that all older people -- 70 years and above -- with cancer should receive a comprehensive geriatric assessment to optimize their clinical care and health outcomes," Soo concluded.
Ian Ingram joined MedPage Today in 2018 as Deputy Managing Editor, and covers oncology for the site.
Lee had no conflicts to disclose.
Soo reported relationships with Medibank and Sonic Healthcare.
Source Reference: Lee A, et al "Changes in cancer mortality rates after the adoption of the Affordable Care Act" ASCO 2020; Abstract 2003.
Source Reference: Soo WK, et al "Integrated geriatric assessment and treatment (INTEGERATE) in older people with cancer planned for systemic anticancer therapy" ASCO 2020; Abstract 12011.