乌鸦传媒

CHICAGO -- States that expanded Medicaid coverage had significantly greater declines in gastrointestinal (GI) cancer mortality as compared with states that did not expand the government-sponsored health insurance, particularly among Black patients, a large cross-sectional study showed.

Mortality for pancreas, colorectal, and gastric cancer declined in states that did and did not expand Medicaid, but the declines were greater in the expansion states. Among white patients, only colorectal cancer (CRC) mortality declined more in association with Medicaid expansion. Mortality for all three types of GI cancer declined significantly more for Black patients living in states that expanded Medicaid under the Affordable Care Act (ACA).

Following Medicaid expansion, mortality for all three types of cancer was similar between Black and white patients, reported Naveen Manisundaram, MD, of the University of Texas MD Anderson Cancer Center in Houston, during a press briefing ahead of the American Society of Clinical Oncology (ASCO) annual meeting.

"There was an improvement in mortality over time for patients in both expansion and non-expansion states," said Manisundaram. "For Black patients, in particular, improvements in mortality rates were consistently higher in expansion states than in non-expansion states. Improvements in mortality for Black patients were even more pronounced in advanced-stage disease."

"These improvements in survival resulted in reductions of existing racial survival disparities in patients with pancreatic and gastric cancer," he added. "Thus, expanding Medicaid is one attainable and concrete solution that has been found to be associated with improved survival."

Well-documented disparities in access to cancer treatment and survival exist for racial minorities and other disadvantaged populations. The ACA provided federal funding to participating states to improve access to disadvantaged populations by expanding Medicaid eligibility criteria, but the decision to expand eligibility was left to the individual states. The impact of expansion on survival disparities in GI cancers remained unclear.

Manisundaram and colleagues examined the effect of Medicaid expansion on racial disparities and 2-year mortality in patients with any stage of three GI malignancies -- pancreatic ductal adenocarcinoma (PDAC), CRC, and gastric cancer. They performed separate analyses for late-stage disease.

Using the , investigators performed a (DID) analysis to compare adjusted 2-year mortality for Black and white patients residing in Medicaid expansion and non-expansion states before (2009-2013) and after (2014-2019) expansion. They also evaluated receipt of surgery and chemotherapy.

The analysis included a total of 86,052 patients: 19,188 with PDAC, 60,404 with CRC, and 6,460 with gastric cancer. The study population comprised 22,109 Black patients and 63,943 white patients.

The 2-year mortality improved in expansion and non-expansion states alike, but the magnitude of improvement was greater in states that expanded Medicaid coverage. Race-based disparities in mortality improved in expansion states but remained the same or worsened in non-expansion states.

For pancreatic cancer, 2-year mortality in Black patients decreased by 11.8% in expansion states versus the pre-expansion era as compared with a decline of 2.4% for Black patients in non-expansion states. For late-stage disease, 2-year mortality among Black patients decreased by almost 10 percentage points in expansion versus non-expansion states, whereas mortality among white patients was almost three percentage points lower in non-expansion states.

The 2-year mortality for CRC declined by 4.2% among white patients and by 2.9% for Black patients in expansion versus non-expansion states. For late-stage disease, Black patients had a 6.4% absolute reduction in mortality for the comparison of expansion versus non-expansion states versus a decline of 2.9% for white patients.

For gastric cancer, 2-year mortality improved by 7.7% for Black patients residing in expansion states versus a 3.7% absolute increase in white patients. For late-stage disease, white patients living in non-expansion states had a 5.4% absolute improvement in mortality versus those living in expansion states. For Black patients the opposite was true, as 2-year mortality exhibited a 7.7% absolute decrease overall and a 10.6% absolute decrease for late-stage disease for the comparison of expansion versus non-expansion states.

Use of chemotherapy for advanced PDAC and gastric cancer increased among Black patients in expansion versus non-expansion states, and use of surgery for advanced CRC increased among Black patients in expansion states.

"Everyone, everywhere should have access to the best possible care; yet, in the United States, people in minority populations continue to experience disparities in cancer treatment and survival," said Julie Gralow, MD, ASCO's chief medical officer, in a statement. "The findings of this study provide a solid step for closing the gap, showing that the Medicaid expansion opportunity offered by the Affordable Care Act ... results in better cancer outcomes and mitigation of racial disparities in cancer survival."

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