More cancers were diagnosed in early stage, including female breast cancer, following an increase in health insurance coverage from the Affordable Care Act (ACA), according to a new study presented at the 2017 ASCO Annual Meeting (Abstract 6521).
An analysis of nearly 273,000 patients showed that between 2013 and 2014 there was a 1 percent increase in the percentage of breast, lung, and colorectal cancers diagnosed at the earliest, most treatable stage, which could add up to a significant number of new cases and potentially lead to better outcomes.
This study is the first to explore changes in the proportion of cancers—those that can be detected through screening—diagnosed at stage I following full implementation of the ACA.
“We know from previous research that lack of insurance typically results in diagnosis of cancer at a later, and usually less treatable, stage,” said lead study author Xuesong Han, PhD, Strategic Director, Health Policy and Healthcare Delivery Research, American Cancer Society. “Although we only analyzed data from a limited timeframe, the fact that there appears to be a positive trend in diagnosis at an earlier stage in multiple cancers is an encouraging sign.”
Studying the ACA
The five types of cancers analyzed in this study have screening methods that allow for detection at an early stage, though in some instances, debate remains over efficacy and appropriate use: mammography for breast cancer, colonoscopy for colorectal cancer, Pap smear and/or HPV test for cervical cancer, spiral computed tomography or CT for lung cancer, and PSA test for prostate cancer.
The researchers used the National Cancer Database, a nationally hospital-based cancer registry capturing 70 percent new cancer cases in the U.S. each year, to identify non-elderly cancer patients with screening-appropriate age who were diagnosed during 2013-2014. As the ACA was implemented in late 2013, they used the first 9 months of 2013 as a baseline and compared trends in cancer stage at diagnosis in this period to those in the last 9 months of 2014.
The study included 121,855 female breast cancer patients, ages 40-64 years; 39,568 colorectal cancer patients, ages 50-64 years; 11,265 cervical cancer patients, ages 21-64 years; 59,626 prostate cancer patients, ages 50-64 years; and 41,504 lung cancer patients, ages 55-64 years.
The results show a 1 percent increase in stage I diagnoses for four of the five cancers detectable by screening: breast (from 47.8% to 48.9%) and cervical cancer (47.3% vs. 48.8%, a difference that was not statistically significant) in women; and lung (from 16.6% to 17.7%) and colorectal cancer (22.8% vs. 23.7%) in men and women. The exception was prostate cancer: the percentage of stage I diagnoses fell by 1 percent (from 18.5% to 17.2%). Han suggested that a reason for the lower prostate cancer detection rate may be the U.S. Preventive Services Task Force recommendation against PSA-based screening for prostate cancer.
The researchers also identified changes in early diagnosis in states by Medicaid expansion. “Although early stage diagnosis increased, statistically significant increases were seen only for colon cancer and lung cancer in Medicaid expansion states. Regardless of Medicaid status, female breast cancer improved and prostate cancer decreased,” said Han.
More research is needed to see if shifts in stage at diagnosis is a short-term effect or continues over time, Han added. “More people are gaining access to screening services.”
The researchers plan to follow cancer diagnosis trends over the coming years. They also plan to look beyond these five cancers and examine patterns in population databases that are more generalizable.
In conclusion, Han said: “ACA implementation was significantly associated with a shift to early stage at diagnosis for female breast, colorectal, and lung cancer. Shift to female breast cancer was regardless of Medicaid expansion status. Shifts to early stage for colorectal and lung cancer were mainly seen in Medicaid expansion states.”
ASCO President-Elect Bruce E. Johnson, MD, Professor of Medicine at Harvard Medical School, Boston, commented: “Cancer is most curable when it is detected at its earliest stages. While it is much too soon to identify the specific cause of this positive trend, or determine whether it is sustainable and will improve outcomes, it is indeed a step in the right direction.”
He added: “This is an important study even though the changes are not that dramatic. Uptake of screening is slow, which is consistent with the idea that additional screening will find more stage I patients. The earlier stage the disease is detected, the more likely it will be cured.”
ASCO emphasizes ease of access to screening, Johnson noted. “In the ACA, most cancer screening is covered. Whatever health care plan is put in place eventually by Congress, oncologists need to advocate early access to screening of cancer in its curable forms,” he said.
Mark L. Fuerst is a contributing writer.