Medicaid Expansion Reduced Racial Disparities in Cancer Treatment

MedicalResearch.com Interview with:

Blythe J.S. Adamson, PhD, MPH Senior Quantitative Scientist Flatiron Health

Dr. Adamson

Blythe J.S. Adamson, PhD, MPH
Senior Quantitative Scientist
Flatiron Health

MedicalResearch.com: What is the background for this study?

Response: Racial disparities in access and outcomes have been documented across the full trajectory of cancer-related care. This includes access to prevention and screening, to early diagnosis, treatment, survival and other health outcomes. While these disparities have been well documented, finding mechanisms to reduce disparities is more challenging. One potential mechanism to reduce treatment disparities is to improve access to insurance coverage. The Affordable Care Act (ACA), passed in March 2010, included as its overall goals the improvement in healthcare quality and access, and enhancing equity in treatment and outcomes. The ACA allowed states to expand Medicaid to poor and near-poor adults, and this was implemented by many states starting in 2014. In addition, the ACA established private insurance marketplaces with income-based premium subsidies and limits on out-of-pocket spending for qualifying low-income enrollees.

Prior research has demonstrated that ACA Medicaid expansions are associated with increased coverage and improved overall access for cancer survivors; and for newly diagnosed patients, the ACA was associated with increased coverage and shifts to earlier stage diagnosis for some cancers. To our knowledge, no research has yet demonstrated that the ACA coverage expansions affected the process of cancer care, specific cancer treatments received or specific treatment outcomes, let alone whether disparities were reduced.  In this study we looked at the time from advanced/metastatic diagnosis to start of systemic treatment for black vs. white patients and based on whether they were diagnosed at a time and in a state that had vs. had not implemented Medicaid expansion. Our study hypothesis was that Medicaid expansion reduced disparity in timely treatment of black patients compared to white patients with advanced cancer. We defined timely treatment as start of systemic therapy within 30 days of advanced/metastatic diagnosis.

This is a retrospective observational study, not a randomized controlled trial. In other words, we selected a cohort of patients diagnosed with advanced or metastatic cancers over time and observed whether they received timely treatment. The Flatiron Health EHR-derived database was the principal data source for this research. Flatiron contributing practices include 280 cancer community based clinics and academic hospital outpatient settings (~800 sites of care) representing more than 2.2 million patients with cancer in the United States. Practices are located in 40 states. To produce the database, Flatiron extracted data from structured fields, including demographics, and recorded medication orders and administrations. Flatiron also abstracted unstructured data, using technology assisted review by highly trained clinicians. Abstracted data include diagnosis date, stage, and prescribed oral anticancer medications. The database used for research purposes was de-identified. We also used data from the Kaiser Family Foundation which has tracked Medicaid implementation policies for over twenty years, and the US Bureau of Labor Statistics from which we pulled state-year unemployment rates.

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Older Women With Early Breast Cancer May Have A Choice of Radiation Therapy Alone

MedicalResearch.com Interview with:

Manjeet Chadha, MD, MHA, FACR, FASTRO Prof. Radiation Oncology Director of the Department of Radiation Oncology Mount Sinai Downtown 

Prof. Chadha

Manjeet Chadha, MD, MHA, FACR, FASTRO
Prof. Radiation Oncology
Director of the Department of Radiation Oncology
Mount Sinai Downtown 

MedicalResearch.com: What is the background for this study?

Response: Largely, the goal of cancer care among the elderly is to de-escalate therapy searching for a modality that is both an effective treatment and also associated with minimal toxicity.

Approximately, 30% of new breast cancers diagnosed annually are among women older than 70 years of age. Age-adjusted trends note a relatively higher incidence of stage I breast cancer in women between the ages of 70-74 years. For this group of patients, it is imperative that we take a closer look at the evidence-base for our current practice standards, and evaluate opportunities to improve cancer care delivery in the elderly.

Randomized trials have helped arrive at an acceptance of adjuvant endocrine monotherapy in older patients with ER positive, node negative breast cancer. However, in the older patients high rates of non-compliance to tamoxifen secondary to poor tolerance is widely recognized. Emerging data also detail the side effect profile of aromatase inhibitors. Most commonly observed symptoms of arthralgia, reduced bone mineral density, and increased risk of fractures throughout the duration of treatment are important considerations for an older population. At least a quarter of patients on aromatase inhibitors discontinue therapy specifically due to skeletal events and musculoskeletal symptoms. Overall, the side effects of ET contribute to a high rate of non-compliance and negative impact on patients’ quality of life.

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Higher Socioeconomic Status Linked to More Use of Complementary Medicine

MedicalResearch.com Interview with:

James Yu, MD, MHS Director of Yale Medicine's Prostate & Genitourinary Cancer Radiotherapy Program

Dr. James Yu

James YuMDMHS
Director of Yale Medicine’s Prostate & Genitourinary Cancer Radiotherapy Program

MedicalResearch.com: What is the background for this study?

Response: We previously investigated alternative medicine (therapy used instead of conventional medicine) and showed its use (vs. non-use) was associated with an increased risk of death, but we did not investigate complementary medicine (non-medical therapy used in addition to conventional medicine).  Approximately two-thirds of cancer patients believe CM will prolong life and one-third expect it to cure their disease despite lack of evidence to support this.

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Yin Yang 1 Regulatory Protein May Help Breast Cancer Evade Treatment

MedicalResearch.com Interview with:

Luca Magnani, Ph.D CRUK Fellow/Senior Research Fellow Department of Surgery and Cancer Imperial Centre for Translational and Experimental Medicine Room 140 1st floor ICTEM building Imperial College Hammersmith London, UK

Dr. Magnani

Luca Magnani, Ph.D
CRUK Fellow/Senior Research Fellow
Department of Surgery and Cancer
Imperial Centre for Translational and Experimental Medicine
Room 140 1st floor ICTEM building
Imperial College Hammersmith
London, UK

MedicalResearch.com: What is the background for this study? Would you briefly explain what is meant by the Yin Yang1 molecule?

Response: This study was designed to investigate the evidence of non-genetic mechanisms that could contribute to breast cancer biology. Specifically, we developed a map of regulatory regions from luminal breast cancer patients. Regulatory regions are pieces of DNA that are not transcribed into protein-coding genes but they provide information about where and how much each gene should be activated.

It is worth highlighting that cancer is not only the consequence of gene mutations but also the result of the wrong genes expressed at the wrong time.  To catalogue regulatory regions we looked for specific modifications that are strongly associated with their activity (epigenetic modifications). Doing so we developed the first extensive catalogue  of non-coding DNA regions that might play an essential role in regulating how breast cancer cell behaves. Regulatory regions do their job by interacting with specific molecules called transcription factors. These molecules can read the information stored in these regulatory regions and contribute to regulate gene expression. Yin Yang 1 is one of such molecules and was previously thought as a ambiguous player capable of activating or repressing gene activity.   Continue reading

Eradicating disseminated tumors, even in brain, by injecting specific antibodies

MedicalResearch.com eInterview with Ronald Levy, M.D.
Professor and Chief Division of Oncology
Stanford University, 269 Campus Drive
Stanford, California 94305, USA

MedicalResearch.com: What are the main findings of the study?

Dr. Levy: Injection of antibodies that deplete Treg cells directly into a tumor can evoke an immune response that cures  the animal of distant, untreated tumors.

This effect eliminates cancer even in the brain.

The dose of antibodies locally injected can be as low as 1/100 the dose used for systemic injection and therefore should avoid the usual autoimmune side effects of these antibodies.
The antibodies used are directed against CTLA4 and OX40 antigens.

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Researchers reveal ways to make personalized cancer therapies more cost effective

AURORA, Colo. — As scientists continue making breakthroughs in personalized cancer treatment, delivering those therapies in the most cost effective manner has become increasingly important. Now researchers at the University of Colorado School of Medicine have identified new ways of doing just that, allowing more patients to benefit from this revolution in cancer care.

In a paper published in the British Journal of Cancer, health economist Adam Atherly, PhD, of the Colorado School of Public Health (CSPH) and medical oncologist D. Ross Camidge, MD, PhD, of the University of Colorado Cancer Center, argue the cost of profiling patients’ tumors for specific molecular abnormalities must be considered. This kind of molecular profiling is increasingly being used to determine who would benefit most from a variety of cancer drugs. In addition, many new drugs are now being restricted to cancer patients with specific molecular sub-types of the disease. Many of these initial breakthroughs have happened in lung cancer, but dividing one disease into many different sub-diseases at the molecular level is expected to extend across most of cancer medicine in the next few years.

“In recent years, we have championed the practice of performing very sophisticated molecular tests on the tumors of every lung cancer patient we see. We then use this information to direct patients to the most appropriate targeted therapy for their cancer,” said Camidge, CU Cancer Center investigator and director of the thoracic oncology clinical program at University of Colorado Hospital (UCH).

Camidge continues, “The testing has certainly led to major breakthroughs in the treatment of lung cancer. But if we are going to roll these developments out across the U.S. and around the world, we have to understand what this progress costs and how to make it affordable.”

Many insurers already consider the cost of a drug and the benefit derived from its use when determining coverage. In their paper, Atherly and Camidge reveal that the cost of testing tumors for an increasing array of specific genetic abnormalities must now also be considered.

“If you screen every patient with a molecular test to detect something that only occurs in one percent of them – in reality, treating each positive patient should also include the upfront costs of screening the other 99 negative patients,” said Atherly, professor of health systems management and policy for the Colorado School of Public Health. “If a test costs $1,000, this means from society’s perspective you have to add $100,000 to the costs of treating each of the one in 100 patients that are positive. And this is before you have even started to consider the cost of the drug itself. When you consider these factors, some organizations may not view a new drug as cost effective even if it works amazingly well for the small percentage who are proven positive by the test.”

Using recent breakthroughs by the University of Colorado’s lung cancer program to model their data, Atherly and Camidge argue pricing of the molecular profiling tests and policies on who and how to screen for abnormalities should be carefully considered or treatment of many different cancers may be delayed. They suggest two key ways molecular profiling can be made more cost effective. First, clinicians could recommend testing only some patients based on finding certain key clinical factors that increase the chances of a patient having a specific molecular abnormality in their tumor. The downside is that some positive patients may be missed if they don’t fit a classical stereotype. Second, either the cost of the profiling test for each individual molecular abnormality has to be reduced for every patient screened, or tests must be merged so doctors can look for multiple different abnormalities at the same time at a lower combined price.

“We believe the only way to beat cancer is moving away from the one-size-fits-all model,” said Camidge. “To do this we must treat every person as an individual. But if we don’t think now about the costs of this approach and how to address them, these breakthroughs will never achieve their true potential.”