Abstract
BackgroundSocioeconomic 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.MethodsWe 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.ResultsThere 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).ConclusionsThe 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.
Highlights
Socioeconomic differences in receipt of adjuvant treatment contribute to persistent disparities in breast cancer (BCA) outcomes, including survival
Data source Our primary data source is the Massachusetts Cancer Registry (MCR), which is administered by the Massachusetts Department of Public Health and follows standards set by the North American Association of Central Cancer Registries (NAACCR), the Commission on Cancer (CoC), the National Cancer Institute (NCI), and the Centers for Disease Control and Prevention (CDC) [37]
In lower-income ZIP code areas, we observed an increase of 8.8 percentage points in the proportion of BCA patients who initiated Adjuvant endocrine therapy (AET) after surgery; in higher-income ZIP code areas, there was an increase of 4.2 percentage points
Summary
Socioeconomic differences in receipt of adjuvant treatment contribute to persistent disparities in breast cancer (BCA) outcomes, including survival. Breast cancer (BCA) is the second most common cancer and the second leading cause of cancer death among women in the US [1] This is the case in the state of Massachusetts, where about 30% of new cancer cases. Several randomized clinical trials of tamoxifen and aromatase inhibitors (AIs) established their positive effects on overall, disease-free, and recurrence-free survival [8,9,10,11,12,13,14,15,16,17,18] Given this evidence, American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) guidelines recommend use of tamoxifen for BCA in premenopausal women and the use of an AI for postmenopausal women, either as primary therapy, as sequential therapy, or in the extended adjuvant setting [19, 20]
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