Disparities in time to prostate cancer treatment initiation before and after the Affordable Care Act

• Type of Material: Article
• Authors: James Janopaul-Naylor, Emory University; Taylor Jones Corriher, Emory University; Jeffrey M. Switchenko, Emory University; Sheela Hanasoge, Emory University; Ashanda Esdaille, Emory University; Brandon A Mahal, University of Miami; Christopher Filson, Emory University; Sagar A Patel, Emory University
• Language: English
• Date: 2023-08-03
• Publisher: John Wiley and Sons
• Publication Version: Final Published Version
• Copyright Statement: © 2023 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): https://doi.org/10.1002%2Fcam4.6419
• Title of Journal or Parent Work: Cancer Medicine
• Volume: 12
• Issue: 17
• Start Page: 18258
• End Page: 18268
• Grant/Funding Information: Research reported in this publication was supported in part by the Biostatistics Shared Resource of Winship Cancer Institute of Emory University and NIH/NCI under award number P30CA138292.
• Keywords: treatment delay; health disparities; prostate cancer; healthcare systems; insurance coverage
• Research Categories: Health Sciences, Public Health; Health Sciences, Oncology

Abstract

Background: Delayed access to care may contribute to disparities in prostate cancer (PCa). The Affordable Care Act (ACA) aimed at increasing access and reducing healthcare disparities, but its impact on timely treatment initiation for PCa men is unknown. Methods: Men with intermediate‐ and high‐risk PCa diagnosed 2010–2016 and treated with curative surgery or radiotherapy were identified in the National Cancer Database. Multivariable logistic regression modeled the effect of race and insurance type on treatment delay >180 days after diagnosis. Cochran–Armitage test measured annual trends in delays, and joinpoint regression assessed if 2014, the year the ACA became fully operationalized, was significant for inflection in crude rates of major delays. Results: Of 422,506 eligible men, 18,720 (4.4%) experienced >180‐day delay in treatment initiation. Compared to White patients, Black (OR 1.79, 95% CI 1.72–1.87, p < 0.001) and Hispanic (OR 1.37, 95% CI 1.28–1.48, p < 0.001) patients had higher odds of delay. Compared to uninsured, those with Medicaid had no difference in odds of delay (OR 0.94, 95% CI 0.84–1.06, p = 0.31), while those with private insurance (OR 0.57, 95% CI 0.52–0.63, p < 0.001) or Medicare (OR 0.64, 95% CI 0.58–0.70, p < 0.001) had lower odds of delay. Mean time to treatment significantly increased from 2010 to 2016 across all racial/ethnic groups (trend p < 0.001); 2014 was associated with a significant inflection for increase in rates of major delays. Conclusions: Non‐White and Medicaid‐insured men with localized PCa are at risk of treatment delays in the United States. Treatment delays have been consistently rising, particularly after implementation of the ACA.