Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
Department of Urology, New York Presbyterian-Weill Cornell Medical College, New York, New York, USA.
Cancer. 2020 Jul 15;126(14):3229-3236. doi: 10.1002/cncr.32930. Epub 2020 Apr 28.
The objective of this study was to determine the effect of Medicaid expansion under the Patient Protection and Affordable Care Act (January 1, 2014) on the epidemiology of high-risk prostate-specific antigen (PSA) levels (≥20 ng/mL) at the time of prostate cancer (PCa) diagnosis. The authors hypothesized that better access to care would result in a reduction of high-risk features at diagnosis.
A retrospective cohort study was performed of 122,324 men aged <65 years who were diagnosed with PCa within the National Cancer Database. Difference-in-difference (DID) analyses adjusting for sociodemographic variables using linear regression compared PSA levels at diagnosis before expansion (2012-2013) and after expansion (2015-2016) between men residing in states that did or did not expand Medicaid.
From 2012 to 2016, the proportion of men with PSA levels ≥20 ng/mL increased (from 18.9% to 19.8%) in nonexpansion states and decreased (from 19.9% to 18.2%) in expansion states. Compared with men in nonexpansion states, men in expansion states experienced a decline in PSA ≥20 ng/mL (DID, -2.33%; 95% CI, -3.21% to -1.44%; P < .001). Accordingly, the proportion of men presenting with high-risk disease decreased in expansion states relative to nonexpansion states (DID, -1.25%; 95% CI, -2.26% to 0.25%; P = .015). A similar statistically significant decrease in PSA levels ≥20 ng/mL was noted among black men (DID, -3.11%; 95% CI, -5.25% to 0.96%; P = .005).
In Medicaid expansion states, there was an associated decrease in the proportion of young men presenting with PSA ≥20 ng/mL at the time of PCa diagnosis. These results suggest that Medicaid expansion improved access to PCa screening. Longer term data should assess oncologic outcomes.
本研究旨在确定《患者保护与平价医疗法案》（2014 年 1 月 1 日）实施的医疗补助计划扩大范围对前列腺癌（PCa）诊断时高风险前列腺特异性抗原（PSA）水平（≥20ng/ml）的流行病学的影响。作者假设更好的医疗保健可降低诊断时的高危特征。
对国家癌症数据库中 122324 名年龄<65 岁的 PCa 男性患者进行回顾性队列研究。采用线性回归通过调整社会人口统计学变量的差异（DID）分析，比较了在未扩大医疗补助计划的州（2012-2013 年）和扩大医疗补助计划的州（2015-2016 年）之间，诊断时 PSA 水平在扩张前（2012-2013 年）和扩张后（2015-2016 年）的差异。
2012 年至 2016 年，未扩大医疗补助计划的州中 PSA 水平≥20ng/ml 的男性比例从 18.9%上升到 19.8%（P<0.001），而在扩大医疗补助计划的州中则从 19.9%下降到 18.2%。与未扩大医疗补助计划的州相比，扩大医疗补助计划的州的 PSA≥20ng/ml 下降（DID，-2.33%；95%CI，-3.21%至-1.44%；P<0.001）。因此，与未扩大医疗补助计划的州相比，扩大医疗补助计划的州中表现出高危疾病的男性比例下降（DID，-1.25%；95%CI，-2.26%至 0.25%；P=0.015）。在黑人男性中，PSA 水平≥20ng/ml 也有类似的统计学显著下降（DID，-3.11%；95%CI，-5.25%至 0.96%；P=0.005）。
在扩大医疗补助计划的州，PSA≥20ng/ml 的年轻男性在 PCa 诊断时的比例下降。这些结果表明，医疗补助计划扩大提高了 PCa 筛查的可及性。更长时间的数据应评估肿瘤学结果。
