Pre-Medicare-aged women with ovarian cancer were more likely to be diagnosed at an early stage and receive treatment within 30 days of diagnosis after passage of the Affordable Care Act (ACA) than before, according to study findings presented at 2019 American Society of Clinical Oncology (ASCO) Annual Meeting. The study highlights the significance of the ACA for many Americans even as the healthcare reform act struggles for survival amid attempts by the Trump administration and Republican-led states to have a federal appeals court declare it unconstitutional. Democrats still defend the system, although some are moving toward support for a single-payer system.
Findings demonstrated that between the years 2006 to 2014, there was a relative gain of 1.7% in early-stage (defined as stage I or II) diagnosis of ovarian cancer in women aged 21 to 64, compared with women ≥65 in the control group, many of whom were presumed to be on Medicare. The 1.7% increase indicates that of the 22,000 women diagnosed annually, approximately 400 more have the potential for ovarian cancer diagnosis at a stage that is both early and treatable, thereby extending potential survival time, lead author Anna Jo Smith, MD, MPH, said.
The study also demonstrated an improvement of 1.6% in women aged 21 to 64 treated within 30 days of diagnosis, compared with the control group. “Our control Medicare group actually had more delays in care during the study period than at the start of the study period. Our treatment group, women impacted by the ACA, had a slight improvement in timely receipt of care for ovarian cancer,” Smith said.
Among publicly insured women aged 21 to 64, there were relative gains of 2.5% in both the diagnosis of ovarian cancer and time to treatment. Younger women were more likely than older women to receive early diagnosis throughout the study period. About 25% of younger women received an early diagnosis at the start of the study in 2006 versus 35% of younger women in 2014. In addition, roughly 20% of younger women saw delays in treatment of ≥30 days at the start of the study through to the end, whereas for older women the percentages increased, from roughly 27% at the start of the study to around 31% at the end.
Smith, a resident in the Johns Hopkins Department of Gynecology and Obstetrics, at Baltimore, Maryland, and Amanda Nickles Fader, MD, director of the Kelly Gynecologic Oncology Service and an associate professor at Johns Hopkins, evaluated ovarian cancer data from the National Cancer Database, which records data on approximately 70% of all new ovarian cancer cases. They concluded that the ACA led to an increase in ovarian cancer treatment and more treatment occurring within 30 days of diagnosis, thereby increasing chances of survival for women with ovarian cancer.
“Detecting and treating ovarian cancer at an early stage saves lives and lowers healthcare costs compared with treatment of cancer at a more advanced, incurable stage,” said Smith. “Having health insurance plays a major role in whether or not a woman has access to care providers who can monitor symptoms and act on those symptoms if necessary.”
The study authors were able to measure the improvement in ovarian cancer and treatment by using a difference-in-differences approach, which allows analysis using a comparator control group that is unaffected by the changes being evaluated. In this case, the investigators compared younger women with those ≥65 years of age, who would likely be on Medicare and uninfluenced by the passage of ACA.
In the United States, more than 75% of women with early-stage ovarian cancer live 5 years or more; that percentage falls to less than 30% for those diagnosed at an advanced stage. As there is no screening test to detect ovarian cancer at an early stage, the cancer can often be present but undetected for years, due in part to the cancer’s tendency to present subtle symptoms. The coverage that the ACA afforded to an expanded number of Americans enabled women with the cancer to not only visit their doctors, but also report symptoms to their physicians, complete laboratory tests to confirm the presence of cancer, and subsequently receive treatment. The expanded coverage accessible through the ACA rendered early detection of the cancer increasingly possible.
By 2017, nearly 12.7 million individuals gained health coverage following the ACA’s 2010 implementation. Meanwhile, the proportion of uninsured Americans decreased from 16% in 2010 to less than 12% by 2016.
The ACA extended Medicaid coverage to nearly all Americans with incomes at or below 138% of the poverty line in states that adopted the expansion, while making tax credits available for people with higher incomes to purchase coverage through a health insurance marketplace. But recent changes could spell reduction in coverage options and the number of people who sign up for or retain ACA coverage.
ASCO Chief Medical Officer Richard L. Schilsky, MD, said at the findings presentation that ASCO has not adopted any official stand on the future of the ACA or any another health plan advanced through Congress. But he said that ASCO’s core principles state that patients should have access to high quality care delivered by a specialist, the opportunity to be screened for cancer, and the opportunity to participate in clinical trials. “It is clear that there will be an ongoing debate. There has been since the passage of the ACA. I think the data presented here demonstrate the importance of good health insurance as a key driver of access to care, timely diagnosis, timely treatment, and presumably better outcomes. ASCO will continue to advocate for those core principles to be retained in any modification of the ACA that might be put forward,” Schilsky said.
In her remarks, Smith noted the significance of the extension of coverage to women with ovarian cancer. “As stage and treatment are the major determinants of survival in ovarian cancer, these gains under the ACA may have long-term impacts on the survival, health and well-being of women with ovarian cancer.”
The investigators used data on stage at ovarian cancer diagnosis and time to treatment for women aged 21 to 64 and ≥65 who were diagnosed from 2004 to 2009 (pre-ACA; 35,842 patients) and 2011 to 2014 (post ACA; 37,145 patients).
They examined the type of insurance women had and adjusted findings for race, rural demographics, neighborhood household income, education level, distance traveled for care, Census region, and practice setting for care. They also adjusted based on the Charlson comorbidity score, which predicts risk of death within 1 year of hospitalization for people with comorbid conditions.
The study was funded by a Johns Hopkins Department of Gynecology and Obstetrics Kelly Society Grant, and the investigators will expand their purview to include the years beyond 2014, to assess the impact of the ACA on early-stage diagnosis and treatment for women with gynecologic cancers.
Smith AJ, Nickles Fader A. Impact of the Affordable Care Act on early-stage diagnosis and treatment for women with ovarian cancer. Presented at: 2019 ASCO Annual Meeting; Chicago, IL; May 31-June 4, 2019. Abstract LBA5563.