Date Published: June 13, 2018
Publisher: Public Library of Science
Author(s): Xuesong Han, Jingxuan Zhao, Kathryn J. Ruddy, Chun Chieh Lin, Helmneh M. Sineshaw, Ahmedin Jemal, Aamir Ahmad.
Breast cancer in young women tends to be more aggressive, but timely treatment may not be always available, particularly to those without health insurance. We aim to examine whether the dependent coverage expansion under the Affordable Care Act (ACA-DCE) implemented in 2010 was associated with changes in time to treatment among women diagnosed with early stage breast cancer.
A total of 7,176 patients diagnosed with early stage breast cancer in 2007–2009 (pre-ACA) and 2011–2013 (post-ACA) were identified from the National Cancer Database. A quasi-experimental design difference-in-differences (DD) approach was used, with patients aged 19–25 (targeted by the policy) considered as the intervention group, and patients aged 26–34 years (not affected by the policy) as the control group. Changes in the following treatment outcomes were examined: time from diagnosis to surgery, time from surgery to adjuvant chemotherapy, and time from adjuvant chemotherapy to radiation.
Compared with the control group of patients aged 26–34, young patients aged 19–25 experienced a statistically nonsignificant decrease of 2.7 percentage points (95% CI [-1.2, 6.5]) in the uninsured rate. This did not translate into more reduction in delays to surgery (DD = 2.7 days, 95% CI [-3.2, 8.3]), chemotherapy (DD = -1.0 days, 95% CI [-7.2, 5.2]) or radiation (DD = 5.3 days, 95% CI [-15.6, 26.3]) in the younger cohort than the older cohort.
No significant changes in time to treatment were found among young women diagnosed with early stage breast cancer after the implementation of the ACA-DCE. Future studies examining impacts of health care policy reform on breast cancer care are warranted to include patients from low-income families and to consider effects from Medicaid expansion.
Although breast cancer rarely occurs at young age, it still is one of the most common cancers among young adults [1, 2]. Moreover, breast cancer diagnosed in women younger than 35 years tends to be more aggressive and carries a worse prognosis than in older adults . While timely treatment is essential for optimized prognosis and survival of breast cancer, it is not always available to patients without adequate health insurance [4–6]. This may be particularly problematic for young adults, who historically had the highest uninsured rate in the US . In September 2010, the dependent coverage expansion under the Affordable Care Act (ACA-DCE) went into effect, allowing young adults to be covered under their parents’ health plans until they turn 26 years old. ACA-DCE has increased insurance coverage among the target population of young adults aged 19–25 years , as well as among newly diagnosed cancer patients of that age [2, 9]. However, the impact of this policy on access to breast cancer treatment among young women is unknown. This study aimed to examine if there is any change in time to treatment after the implementation of the ACA-DCE among young women diagnosed with early stage breast cancer.
The study sample was composed of 6.0% patients in the intervention group and 94.0% in the control group. The majority of patients were non-Hispanic white (61.8%), privately-insured (78.4%), diagnosed at stage II (59.7%), and without comorbidity at the time of diagnosis (94.1%) (Table 1). After 2010, the uninsured rate decreased from 7.7% to 5.0% among patients aged 19–25 years, and unchanged at 4% among those aged 26–34 years, resulting a nonsignificant net decrease of 2.7 percentage points (ppt) (95% CI [-1.2, 6.5], P = 0.1749) among patients aged 19–25 years compared to those patients aged 26–34 years.
We examined changes in insurance coverage and receipt of treatment among young women diagnosed with early stage breast cancer following the ACA dependent expansion insurance coverage using the NCDB from 2007–2013. We found a nonsignificant net decrease of 2.7 ppt in uninsured rate among patients aged 19–25 years relative to those patients aged 26–34 year following the ACA, which was comparable to the findings of two previous studies on young adult cancer patients using population-based cancer registry data [2, 9], where a net decrease in uninsured rate of 3.1 ppt and 2.0 ppt rate were found respectively. We did not find any significant differences in either age group or between the age groups in pre- to post- ACA changes in receipt of treatment or treatment delays including time from diagnosis to surgery, time from surgery to adjuvant chemotherapy, receipt of adjuvant radiation after lumpectomy, and time from adjuvant chemotherapy to radiation.
In summary, this study found no statistically significant changes in time to breast cancer treatment among women 19–25 years old compared to slightly older women after the implementation of the ACA-DCE. Moving forward, studies examining the impact of the ACA on breast cancer care are warranted to include more patients from low-income families and to take Medicaid expansion into account.