Background: Although the Patient Protection and Affordable Care Act (ACA) has been associated with increased Medicaid coverage among prostate cancer patients, the association between Medicaid expansion with risk group at diagnosis, time to treatment initiation (TTI), and the refusal of locoregional treatment (LT) among patients requires further exploration.Methods: Using the National Cancer Database, we performed a retrospective cohort analysis of all patients aged 40 to 64 years diagnosed with localized prostate cancer from 2011 to 2016. Difference-in-difference (DID) analysis was used to compare changes in insurance status, risk group at diagnosis, TTI, and the refusal of LT among patients residing in Medicaid expansion versus non-expansion states. In a secondary analysis, we used DID to compare changes in the above outcomes among racial minorities versus White patients living in expansion states.Results: Of the 112,434 patients with prostate cancer in our analysis, 50,958 patients lived in Medicaid expansion states, and 61,476 patients lived in non-expansion states. In the adjusted analysis, we found that the proportion of uninsured patients (adjusted DID: −0.87%; 95% confidence interval [95% CI]: −1.28 to −0.46) and patients who refused radiation therapy (adjusted DID: −0.71%; 95% CI: −0.95 to −0.47) decreased more in expansion states compared to non-expansion states. Similarly, we observed that the racial disparity of select outcomes in expansion states narrowed, as racial minorities experienced larger absolute decreases in uninsured status and the refusal of radiation therapy (RT) regimens than White patients following ACA implementation (p< 0.01 for all). However, residence in a Medicaid expansion state was not associated with changes in risk group at diagnosis, TTI, nor the refusal of LT (p> 0.01 for all); racial disparities in TTI were also exacerbated in expansion states following ACA implementation.Conclusions: The association between Medicaid expansion and prostate cancer outcomes and disparities remains unclear. While ACA implementation was associated with increased insurance coverage and decreased refusal of RT, there was no significant association with earlier risk group at diagnosis, TTI within 180 days, or refusal of LT. Similarly, racial minorities in expansion states had larger decreases in uninsured status and the refusal of RT regimens, as well as smaller increases in intermediate-/high-risk disease at presentation than White patients following ACA implementation, but experienced no significant changes in TTI. More research is needed to understand how Medicaid expansion affects cancer outcomes and whether these effects are borne equitably among different populations.
背景：尽管《患者保护与平价医疗法案》（ACA）的实施与前列腺癌患者中医疗补助覆盖率的提高有关，但医疗补助扩大政策与患者诊断时的风险分组、治疗启动时间（TTI）以及局部区域治疗（LT）拒绝率之间的关联仍需进一步探讨。 方法：利用国家癌症数据库，我们对2011年至2016年间诊断为局限性前列腺癌的40至64岁患者进行了回顾性队列分析。采用双重差分法（DID）比较了居住在医疗补助扩大州与非扩大州患者在保险状况、诊断时风险分组、TTI以及LT拒绝率方面的变化。在二次分析中，我们使用DID比较了扩大州内少数族裔与白人患者在上述结局指标上的变化差异。 结果：在纳入分析的112,434例前列腺癌患者中，50,958例居住在医疗补助扩大州，61,476例居住在非扩大州。经校正分析发现，与非扩大州相比，扩大州内未参保患者比例（校正DID：-0.87%；95%置信区间[95% CI]：-1.28至-0.46）和拒绝放疗的患者比例（校正DID：-0.71%；95% CI：-0.95至-0.47）下降更为显著。同时我们观察到，扩大州内特定结局的种族差异有所缩小——ACA实施后，少数族裔在未参保状态和拒绝放疗方案方面的绝对降幅均大于白人患者（所有比较p<0.01）。然而，居住在医疗补助扩大州与诊断时风险分组、TTI及LT拒绝率的变化均无显著关联（所有比较p>0.01）；且ACA实施后扩大州内TTI的种族差异反而加剧。 结论：医疗补助扩大政策与前列腺癌治疗结局及差异的关联尚不明确。虽然ACA实施与保险覆盖率提升及放疗拒绝率下降相关，但与早期风险分组诊断、180天内TTI或LT拒绝率无显著关联。同样，ACA实施后扩大州内的少数族裔相较于白人患者，在未参保状态和放疗方案拒绝率方面降幅更大，就诊时中/高风险疾病比例增幅更小，但TTI未见显著改善。需要更多研究来理解医疗补助扩大政策如何影响癌症治疗结局，以及这些影响在不同人群中的分布是否均衡。
肿瘤(癌症)患者之家