Allegheny Health Network, Department of Internal Medicine, Pittsburgh, PA, United States.
Allegheny Health Network Cancer Institute, Division of Medical Oncology, Pittsburgh, PA, United States.
Cancer Treat Res Commun. 2020;24:100204. doi: 10.1016/j.ctarc.2020.100204. Epub 2020 Aug 10.
Patients with advanced cancers are among the most vulnerable group of patients. We sought to analyze the impact of Affordable Care Act (ACA) on the interaction of socioeconomic factors with treatment and survival in patients with metastatic colorectal cancers.
National Cancer Database (NCDB) was queried for patients with Stage-IV colon(CCa) and rectal cancers(R-Ca) diagnosed 2004-2015 and excluded those who did not receive any therapies within 6 months of diagnosis. Enrollment-rates were calculated as receipt of primary therapy as the incident-event (numerator) over time-to-initiation of therapy (denominator) and used to calculate incident-rate ratios that was analyzed using Poisson regression analysis- reported as enrollment-rate ratios (ER, <1 indicating lower enrollment rate). Multivariate Cox-proportional hazard model was performed for survival analysis and reported as calculate Hazard Ratios (HR).
For CCa, enrollment to primary therapies was significantly associated (p-value < 0.05) with gender, race, insurance status, educational status and treatment facility. The HR for non-Hispanic Blacks (NHB) vs. Whites (NHW) improved from 1.1(1.03-1.11),p-value<0.005 to no-significant difference post-ACA. For R-Ca, the enrollment rates were favorable for NHB vs. NHW and ER improved from 1.15(1.0-1.32),p-value = 0.054) to 1.29(1.06-1.58),p-value = 0.013 post-ACA. Despite this, the HR for mortality were unfavorable - 1.19(1.06-1.33),p-value = 0.003 that persisted through the post-ACA period. The HR was favorable for the insured group in both cancer groups (0.84 for R-Ca,0.86 for CCa) and for high-income vs. low-income group-0.90(0.87-0.94),p-value < 0.005 in CCa.
The ACA appears to have had a positive impact overall but further research and ongoing interventions are warranted to mitigate disparities in this population.
晚期癌症患者属于最脆弱的患者群体之一。我们试图分析平价医疗法案（ACA）对转移性结直肠癌患者中社会经济因素与治疗和生存相互作用的影响。
国家癌症数据库（NCDB）被查询了 2004 年至 2015 年期间诊断为 IV 期结肠癌（CCa）和直肠癌（R-Ca）的患者，并排除了在诊断后 6 个月内未接受任何治疗的患者。登记率计算为接受主要治疗作为事件（分子）除以治疗开始时间（分母），并用于分析泊松回归分析报告的发病率比值，以登记率比值（ER，<1 表示登记率较低）表示。多变量 Cox 比例风险模型用于生存分析，并报告为计算风险比（HR）。
对于 CCa，登记接受主要治疗与性别、种族、保险状况、教育程度和治疗机构显著相关（p 值<0.05）。非西班牙裔黑人（NHB）与白人（NHW）的 HR 从 1.1（1.03-1.11），p 值<0.005 改善为 ACA 后无显著差异。对于 R-Ca，NHB 比 NHW 的登记率更有利，ER 从 1.15（1.0-1.32），p 值=0.054 改善为 1.29（1.06-1.58），p 值=0.013 ACA 后。尽管如此，死亡率的 HR 仍不利 - 1.19（1.06-1.33），p 值=0.003，这一趋势在 ACA 后时期仍持续存在。在这两个癌症组中，保险组的 HR 均有利（R-Ca 为 0.84，CCa 为 0.86），高收入与低收入组的 HR 有利 - 0.90（0.87-0.94），p 值<0.005 在 CCa。
ACA 似乎总体上产生了积极影响，但需要进一步研究和持续干预，以减轻该人群的差异。
