State public welfare spending and racial/ethnic disparities in overall survival among adults with cancer.

Abstract

6509 Background: State public welfare spending may partially address social determinants of health and mitigate structural racism. However, its association with racial and ethnic disparities and overall survival for newly diagnosed patients with cancer is unknown. Methods: Adults ages 18 and older with a new cancer diagnosis from 2007-2016 were queried from the Surveillance, Epidemiology, and End Results program. Annual state spending data were obtained from the US Census Bureau. We evaluated the association of 5-year overall survival (OS) and public welfare spending using cluster-robust regression. Analyses were conducted overall, by race and ethnicity, and by cancer site. To determine whether public welfare spending was associated with changes in racial and ethnic disparities in survival, we additionally assessed for interaction effects between public welfare spending and race and ethnicity. Analyses were adjusted for covariates including age, sex, metropolitan residence, state, county-level income and education, insurance status, cancer site, stage at diagnosis, and year of diagnosis. Sensitivity analyses were conducted also accounting for state Medicaid expansion effects and state spending on health care and hospitals. Results: A total of 2,925,550 individuals were identified in our cohort. 5-year OS was 10.6% lower in non-Hispanic Black vs. White patients. Public welfare spending was not associated with 5-year OS overall (0.25 % per 10% increase in spending, -1.47 to 1.96, p =.78) or for non-Hispanic White patients (0.52% per 10% increase in spending, 95% CI -1.30 to 2.33, p =.58). However, increased public welfare spending was associated with increased 5-year OS among non-Hispanic Black patients (2.02% per 10% increase in spending, 95% CI = 0.01 to 4.03, p =.049). There was a 4.46% (95% CI = 2.63 to 6.30, pinteraction<.001) narrowing of the 5-year OS disparity in non-Hispanic Black relative to White patients per 10% increase in spending, or a 42% closure of the 10.6% OS disparity. Specifically, increased public welfare spending was associated with a narrowed Black vs. White 5-year OS disparity for patients with breast (7.50% increase in 5-yr OS for non-Hispanic Black relative to White per 10% increasing in spending, corresponding to closing 42.1% of the disparity), cervical (12.2%, 45.9%), colorectal (3.37%, 44.9%), head and neck (8.23%, 35.7%), liver (4.54%, 44.8%), lung (1.76%, 63.3%), ovarian (6.43%, 35.9%), prostate (2.89%, 41.9%), bladder (7.62%, 42.9%), and uterine cancers (14.9%, 40.9%). Results were similar after accounting for state health care and hospital spending and state Medicaid expansion effects. Conclusions: State investment in public welfare was associated with improved 5-year OS for non-Hispanic Black individuals with cancer, decreasing racial disparities in cancer outcomes overall and for many cancer sites.