High Initiation of Adjuvant Hormonal Therapy Among Uninsured Stages I–III Breast Cancer Patients Treated in a Safety-Net Healthcare System

Murphy, Caitlin C.; Tiro, Jasmin A.; Jean, Gary W.; Balasubramian, Bijal A.

doi:10.1089/jwh.2016.6099

Cited by 5 publications

(8 citation statements)

References 20 publications

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“…The comparatively small effect magnitude of clinical and neuroimaging follow‐up visits on these outcomes in comparison with an SNH setting could potentially be due to challenges in quantifying the quality of follow‐up, such as differentiating symptom‐triggered visits from routine visits, accounting for differences in clinical follow‐up visits due to varying systemic therapy regimens, and determining whether patients received care at institutions outside our health care network . Nonetheless, our results suggest that there may be other unaccounted‐for risk factors associated with an SNH practice setting, such as more patient comorbidities, less access to and compliance with systemic therapies, fewer hospital resources, and a lower quality of medical care …”

Section: Discussionmentioning

confidence: 88%

“…22 Nonetheless, our results suggest that there may be other unaccounted-for risk factors associated with an SNH practice setting, such as more patient comorbidities, less access to and compliance with systemic therapies, fewer hospital resources, and a lower quality of medical care. [23][24][25][26] There are numerous possible explanations for the disparity in the number of neuroimaging follow-up visits at the 2 hospitals, including differences in age, race, income, education, language, social supports, distance from the treatment center, access to transportation, ability to take time off from work, and severity of disease. 23 The fact that SNH patients still received similar clinical follow-up suggests that the underlying reasons are either specific to neuroimaging or affect compliance with neuroimaging studies more than clinical visits.…”

Section: Discussionmentioning

confidence: 99%

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Safety‐net versus private hospital setting for brain metastasis patients treated with radiosurgery alone: Disparities in follow‐up care and outcomes

Diao

Sun

Yoo

et al. 2017

Cancer

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BACKGROUND: Stereotactic radiosurgery (SRS) alone is an increasingly accepted treatment for brain metastases, but it requires adherence to frequently scheduled follow-up neuroimaging because of the risk of distant brain metastasis. The effect of disparities in access to follow-up care on outcomes after SRS alone is unknown. METHODS: This retrospective study included 153 brain metastasis patients treated consecutively with SRS alone from 2010 through 2016 at an academic medical center and a safety-net hospital (SNH) located in Los Angeles, California. Outcomes included neurologic symptoms, hospitalization, steroid use and dependency, salvage SRS, salvage whole-brain radiotherapy, salvage neurosurgery, and overall survival. RESULTS: Ninety-three of the 153 patients were private hospital (PH) patients, and 60 were SNH patients. The median follow-up time was 7.7 months. SNH patients received fewer follow-up neuroimaging studies (1.5 vs 3; P 5.008). In a multivariate analysis, the SNH setting was a significant risk factor for salvage neurosurgery (hazard ratio [HR], 13.65; P <.001), neurologic symptoms (HR, 3.74; P 5.002), and hospitalization due to brain metastases (HR, 6.25; P <.001). More clinical visits were protective against hospitalizations due to brain metastases (HR, 0.75; P 5.002), whereas more neuroimaging studies were protective against death (HR, 0.65; P <.001). CONCLUSIONS: SNH patients with brain metastases treated with SRS alone had fewer follow-up neuroimaging studies and were at higher risk for neurologic symptoms, hospitalization for brain metastases, and salvage neurosurgery in comparison with PH patients. Clinicians should consider the practice setting and patient access to follow-up care when they are deciding on the optimal strategy for the treatment of brain metastases. Cancer 2018;124:167-75. V C 2017 American Cancer Society.KEYWORDS: brain metastases, follow-up care, health disparities, neuroimaging, neurologic outcomes, safety-net hospital, stereotactic radiosurgery. INTRODUCTIONThe standard of care for the treatment of brain metastases has historically been whole-brain radiotherapy (WBRT) with surgery or stereotactic radiosurgery (SRS) as an adjuvant treatment. 1 Recently, SRS alone has become an increasingly accepted treatment option because of the improved neurocognitive preservation demonstrated in 2 randomized controlled trials in comparison with treatment with SRS and WBRT. 2,3 SRS delivers a single, high dose of focal radiation to the tumor while sparing adjacent normal brain tissue and is administered in a single session. Multiple randomized controlled trials have shown no improvement in overall survival (OS) with the addition of WBRT to SRS. 4,5 The success of SRS alone, however, depends on close clinical observation with neuroimaging because of the increased risk of distant brain metastasis failure associated with the omission of WBRT. [3][4][5] Unfortunately, not all patients have equal access to recommended follow-up clinical care, neuroimaging, and salvage treatment. Disparitie...

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Section: Discussionmentioning

confidence: 88%

Section: Discussionmentioning

confidence: 99%

Safety‐net versus private hospital setting for brain metastasis patients treated with radiosurgery alone: Disparities in follow‐up care and outcomes

Diao

Sun

Yoo

et al. 2017

Cancer

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“…A 2004 Massachusetts Health Insurance Survey found that over 90% of newly enrolled Medicaid enrollees after Massachusetts health reform were previously unenrolled [ 35 ]. Previous studies have demonstrated that higher out of pocket prescription drug costs are associated with lower initiation and higher discontinuation of medications and treatments [ 27 , 31 , 32 , 40 – 44 ]. Our study further supports these findings, estimating about a 5-percentage point relative increase in the likelihood of BCA patients aged 20–64 years in low-income areas initiating AET after reform relative to BCA patients in the same age group living in high-income areas.…”

Section: Discussionmentioning

confidence: 99%

Changes in initiation of adjuvant endocrine therapy for breast cancer after state health reform

Eom

Londen

et al. 2021

BMC Cancer

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Background Socioeconomic differences in receipt of adjuvant treatment contribute to persistent disparities in breast cancer (BCA) outcomes, including survival. Adjuvant endocrine therapy (AET) substantially reduces recurrence risk and is recommended by clinical guidelines for nearly all women with hormone receptor-positive non-metastatic BCA. However, AET use among uninsured or underinsured populations has been understudied. The health reform implemented by the US state of Massachusetts in 2006 expanded health insurance coverage and increased the scope of benefits for many with coverage. This study examines changes in the initiation of AET among BCA patients in Massachusetts after the health reform. Methods We used Massachusetts Cancer Registry data from 2004 to 2013 for a sample of estrogen receptor (ER)-positive BCA surgical patients aged 20–64 years. We estimated multivariable regression models to assess differential changes in the likelihood initiating AET after Massachusetts health reform by area-level income, comparing women from lower- and higher-income ZIP codes in Massachusetts. Results There was a 5-percentage point (p-value< 0.001) relative increase in the likelihood of initiating AET among BCA patients aged 20–64 years in low-income areas, compared to higher-income areas, after the reform. The increase was more pronounced among younger patients aged 20–49 years (7.1-percentage point increase). Conclusions The expansion of health insurance in Massachusetts was associated with a significant relative increase in the likelihood of AET initiation among women in low-income areas compared with those in high-income areas. Our results suggest that expansions of health insurance coverage and improved access to care can increase the number of eligible patients initiating AET and may ameliorate socioeconomic disparities in BCA outcomes.

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“…Considering that endocrine therapy is recommended for all patients with HR+ disease, regardless of disease characteristics, the endocrine treatment rate (68.9%) for women with early stage disease was lower than expected [30][31][32]. Other real-world reports have noted similar or higher rates of adjuvant endocrine therapy usage (70-86%), with some highlighting challenges related to adherence and duration of treatment [27,[33][34][35][36][37][38][39][40][41]. Unfortunately, an analysis of factors influencing treatment was beyond the scope of our research, but is warranted in order to optimize outcomes [42] in patients with this subtype of BC.…”

Section: Treatmentmentioning

confidence: 92%

A population-based comparison of treatment patterns, resource utilization, and costs by cancer stage for Ontario patients with hormone receptor-positive/HER2-negative breast cancer

Fathers

Coombes

Pourmirza

et al. 2020

Breast Cancer Res Treat

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Purpose To update and expand on data related to treatment, resource utilization, and costs by cancer stage in Canadian patients with hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2−) breast cancer (BC). Methods We analyzed data for adult women diagnosed with invasive HR+/HER2− BC between 2012 and 2016 utilizing the publicly funded health care system in Ontario. Baseline characteristics, treatment received, and health care use were descriptively compared by cancer stage (I–III vs. IV). Resource use was multiplied by unit costs for publicly funded health care services to calculate costs. Results Our study included 21,360 patients with stage I–III plus 813 with stage IV HR+/HER2− BC. Surgery was performed on 20,510 patients with stage I–III disease (96.0%), with the majority having a lumpectomy, and radiation was received by 15,934 (74.6%). Few (n = 1601, 7.8%) received neoadjuvant and most (n = 15,655, 76.3%) received adjuvant systemic treatment. Seven hundred and fifty eight patients with metastatic disease (93.2%) received systemic therapy; 542 (66.7%) received endocrine therapy. Annual per patient health care costs were three times higher in the stage IV vs. stage I–III cohort with inpatient hospital services representing nearly 40% of total costs. Conclusion The costs associated with metastatic HR+/HER2− BC reflect a significant disease burden. Low endocrine treatment rates captured by the publicly funded system suggest guideline non-adherence or that a fair portion of Ontarian patients may be incurring out-of-pocket drug costs.

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High Initiation of Adjuvant Hormonal Therapy Among Uninsured Stages I–III Breast Cancer Patients Treated in a Safety-Net Healthcare System

Cited by 5 publications

References 20 publications

Safety‐net versus private hospital setting for brain metastasis patients treated with radiosurgery alone: Disparities in follow‐up care and outcomes

Safety‐net versus private hospital setting for brain metastasis patients treated with radiosurgery alone: Disparities in follow‐up care and outcomes

Changes in initiation of adjuvant endocrine therapy for breast cancer after state health reform

A population-based comparison of treatment patterns, resource utilization, and costs by cancer stage for Ontario patients with hormone receptor-positive/HER2-negative breast cancer

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