Medicaid Expansion Through the Affordable Care Act and Receipt of Guideline Recommended Brachytherapy for Locally Advanced Cervical Cancer

Abstract

Brachytherapy is a critical component of definitive chemo-radiation for locally advanced cervical cancer. However, studies have shown that a large portion of patients do not received brachytherapy as part of their treatment. We hypothesized that access to care due to lack of insurance might prevent patients from receiving brachytherapy as part of their treatment, and patients in states that expanded Medicaid under the affordable care act would therefore be more likely to receive brachytherapy after expansion.The National Cancer Database was queried for cases from 2004 to 2016 of women with stage IIb-IVa cervical cancer treated with definitive radiation and chemotherapy. Patients were excluded if they received primary directed surgery, did not receive chemotherapy, had missing or incomplete radiation information, or had their Medicaid expansion status censored due to age < 40. A difference in difference (DID) analysis was performed to compare the uninsured rate and the rate of brachytherapy before and after expansion of Medicaid in states that did vs states that did not expand Medicaid. Multivariable analysis (MVA) for lack of insurance and completion of brachytherapy was adjusted for stage, race, facility type, median income, Charlson comorbidity and insurance (brachy analysis only).A total of 12,409 patients were included with a median age of 55. Most patients were treated at an academic center (50%) and 74% were white. Overall, 56% of patients lived in states that expanded Medicaid early (2010-2013, 21%) or late (2014, 35%). The proportion of patients without insurance significantly decreased in early and late expansion states (-3.2%, -6.6% respectively, P < 0.001) with no significant change in non-expansion states. The decrease in uninsured patients remained significant on multivariable analysis (DID MVA -5.2% early expansion, -6.8% late expansion, P < 0.05). The overall rate of brachytherapy usage increased in expansion states (+8.4% early, +5.0% late expansion, P < 0.001) and in states that did not expand coverage (+4.4%, P < 0.001). However, there was no increase in usage of brachytherapy in expansion states compared to non-expansion states on univariate or multivariate analysis (DID MVA 0.6% [-3.9-5.3] early expansion, -0.2% [-4.6-4.0] late expansion).Medicaid expansion and a subsequent decrease in the uninsured population did not increase the proportion of patients receiving brachytherapy as part of their definitive chemo-radiation for cervical cancer. Our study suggests that lack of insurance, while important, is not the only factor limiting access to standard of care treatment for cervical cancer. Further research into access and availability of brachytherapy is needed.S. Freije: None. E.M. Steele: None. S.E. Robertson: None. O. Ishaq: None. J.A. Holmes: None.