bluuebunny/crossref_metadata_2025_split huggingface dataset:
Association of Medicaid expansion with timely receipt of treatment and survival among patients with HER2-enriched breast cancer.
Authors: Shi Kewei Sylvia , Ji Xu , Jiang Changchuan , Ruddy Kathryn Jean , Castellino Sharon M. , Yabroff Robin , Han Xuesong 
Published: June 2023

6539 Background: HER2-enriched breast cancer (estrogen and progesterone receptors negative and HER2-positive) has no worse prognosis than other breast cancers if it is treated with HER2-targeted therapy. Medicaid expansion under the Affordable Care Act (ACA) has been shown to be associated with improved access to care and outcomes for many cancers, but its impact on care for HER2-enriched breast cancer is unknown. To fill this gap, we examined the association of Medicaid expansion with receipt of guideline-concordant treatment, time to treatment, and survival among newly diagnosed nonelderly women with HER2-enriched breast cancer. Methods: Women aged 18-62 years newly diagnosed with HER2-enriched breast cancer between 2010 and 2018 were identified from the National Cancer Database. Our primary outcomes included receipt of stage-based guideline-concordant treatment, initiation of treatment <60 days, and stage-specific 2-year overall survival. A difference-in-differences (DD) approach compared outcome changes following the expansion in Medicaid expansion vs. non-expansion states. A linear probability model estimated treatment outcome, and a flexible parametric survival model evaluated survival. All models were clustered at the state level and adjusted for age group, race/ethnicity, rurality of residence, zip code-level income, comorbidity, and diagnosis year. Results: A total of 31,354 patients with HER2-enriched breast cancer were included, including 19,255 in expansion states and 12,099 in non-expansion states. Compared to patients in expansion states, patients in non-expansion states were more likely to be racial/ethnic minorities, uninsured, and diagnosed at late-stage. Medicaid expansion was not significantly associated with changes in receipt of surgery for stage I-III disease but was associated with an increase of 4.42 percentage points (ppt, 95% CI: 0.09, 8.74) in receipt of chemotherapy/targeted therapy for stage IV disease, with an increase from 90.4% pre-expansion to 92.8% post-expansion in expansion states and a decrease from 93.7% to 91.9% in non-expansion states. Medicaid expansion was also significantly associated with a 2.41 ppt increase in initiating guideline-concordant treatment within 60 days (95% CI: 0.66, 4.17; 83.5% to 82.5% in expansion states vs. 86.6% to 83.7% in non-expansion states), and a 1.18 ppt increase in two-year survival rate (95% CI: 0.03, 2.33; 94.0% to 94.9% in expansion states vs. 94.3% to 94.1% in non-expansion states). The increase in two-year survival associated with Medicaid expansion was most prominent for stage III patients (DD=3.63 ppt; 95% CI: 0.64, 6.62). Conclusions: Medicaid expansion was associated with increased receipt of timely treatment and improved 2-year survival among nonelderly women newly diagnosed with HER2-enriched breast cancer.
Racial and ethnic disparities in employment of patients and caregivers following breast cancer diagnosis.
Authors: Weiss Marisa C. , Meske Sam , Giaddui Muath , Uscher Jennifer , Manasseh Donna-Marie , Danese Sherry , Ulloa Julie , Thom Bridgette , Chino Fumiko 
Published: June 2023

6543 Background: Breast cancer (BC) can negatively impact employment, risking healthcare benefits, financial security and quality of life, especially for underserved minority populations. To better understand the impact of BC diagnosis and treatment on employment, Breastcancer.org conducted an online survey. Methods: Between 6/7-7/12/2022, Breastcancer.org community members were recruited to participate in an anonymous survey in English or Spanish via email, social media, or website ads. Eligible participants were US residents, age ≥18, and diagnosed with BC within the past 10 years. Consented participants answered questions on socio-demographics, financial toxicity, and employment status. Results: Of 2,420 screened, 1,710 met eligibility, and 1,437 participated (84% participation rate). Mean age and time since diagnosis was 46 and 2 years, respectively; 75% were in active treatment for non-metastatic (89%) or metastatic (11%) BC. Patients identified as 60% White (n=868), 26.7% Hispanic (n=384), 8% Black (n=121), or 4% Other (n=64). 94% were women. BC negatively impacted employment for 92% of patients. Full-time employment went from 62% at diagnosis to 40% by the time of the survey. This was more pronounced in metastatic (56% to 25%) vs non-metastatic (63% to 42%) patients (p=0.015). 64% attributed employment changes to their diagnosis, noting reduced hours/income (40%), job change (26%), disability (13%), permanent job loss (13%), and/or early retirement (12%). 36% noted changes in their caregiver’s employment status as well with 30% of caregivers having reduced hours/income, 30% taking time off work, and 27% changing jobs; 9% of caregivers had permanent job loss and 10% retired early. Hispanic patients were younger (p<0.001) and more likely to have young children (p<0.001) and take unpaid leave (p=0.02). (Table). BC diagnosis was also more likely to impact their caregiver’s employment (58%, vs White 25% or Black 41% patients, p<0.001). Conclusions: Breast cancer can cause significant, lasting negative effects on employment status for patients and caregivers that can decrease financial security of the entire family unit. Hispanic patients and individuals with metastatic disease appear to be at highest risk. Legislative protections and financial support may be required to mitigate the significant financial toxicity of a cancer diagnosis, especially for the most vulnerable. [Table: see text]
Racial disparities in cancer mortality in patients with gastrointestinal malignancies following Medicaid expansion.
Authors: Manisundaram Naveen , Snyder Rebecca A , Hu Chung-Yuan , DiBrito Sandra R. , Chang George J. 
Published: June 2023

6546 Background: Racial minorities experience disparities in receipt of cancer treatment and survival. The optional Medicaid expansion provision of the Affordable Care Act provided federal funding to participating states to improve healthcare access for disadvantaged populations by expanding Medicaid eligibility criteria. This study aimed to investigate the effect of Medicaid expansion on racial disparities in mortality among patients with gastrointestinal malignancies. Methods: A cross-sectional cohort study of patients with pancreatic ductal adenocarcinoma (PDAC), colorectal cancer (CRC), and gastric adenocarcinoma (GC) of any stage was conducted using the National Cancer Database (2009-2019). Difference-in-difference analysis (DID) was performed to compare adjusted 2-year mortality separately among Black and White patients residing in Medicaid expansion states (MES) and non-expansion states (non-MES) before (2009-2013) and after (2014-2019) expansion. Differences in receipt of surgery and chemotherapy were also evaluated. Results: A total of 86,052 patients were included for analysis, including 19,188 patients with PDAC, 60,404 with CRC, and 6,460 with GC. Two-year mortality decreased among Black patients with PDAC residing in MES compared to non-MES following expansion (DID -9.4%, p<0.001) (Table). Mortality also decreased among Black and White patients with CRC in MES compared to non-MES following expansion (DID -4.2%, p < 0.001 and -2.9%, p = 0.047). Among patients with GC, Black patients in MES experienced a marked reduction in mortality compared to non-MES (DID -7.7%, p = 0.07). Both Black and White stage 3-4 PDAC patients had an increase in receipt of chemotherapy in MES following expansion (DID 3.7%, p=0.28 and DID 2.7%, p=0.20). Rates of surgery, but not chemotherapy receipt, increased among Black patients with stage 4 CRC in MES following expansion (DID 5.7%, p=0.03 and 1.0%, p=0.66, respectively). A greater increase in receipt of chemotherapy was observed among Black patients with stage 4 GC in MES than in non-MES (DID 11%, p=0.06). Conclusions: Medicaid expansion was associated with a greater reduction in 2-year mortality rates for Black patients residing in MES than for those in non-MES. Existing racial disparities in mortality remained the same or worsened in non-MES but in almost all cases were mitigated in MES following Medicaid expansion. [Table: see text]
Patient-level interventions to increase guideline concordant treatment among Black breast cancer patients: Can they close the racial gap in survival after diagnosis?
Authors: Yanguela Juan , Jackson Bradford E. , Reeder-Hayes Katherine Elizabeth , Kuo Tzy-Mey , LeBlanc Matthew Roger , Baggett Christopher D , Green Laura , Laurie Erin , Wheeler Stephanie B. 
Published: June 2023

6549 Background: While we have seen impressive improvements in breast cancer (BC) survival over the last few decades, substantial racial disparities persist. Inequities in the receipt of guideline-concordant treatment contribute to worse survival in Black BC patients. Previous studies have shown that patient-level disparity reduction interventions (e.g., patient navigation) can significantly increase guideline-concordant treatment receipt among Black patients, with positive spillover effects in nonBlack patients. The aim of this study was to estimate the potential impact of disparity reduction interventions on racial inequities in survival after BC diagnosis in North Carolina. Methods: We used data from the Cancer Information and Population Health Resource, which links multipayer claims to North Carolina’s cancer registry for biological women diagnosed with BC in 2004-2017. We calculated Black/nonBlack disparities in the receipt of chemotherapy (CTx) within 4 months of diagnosis for patients ages <70 with hormone-receptor negative stage Ib-III BC (CTx cohort; N=2223) and the receipt of endocrine therapy (ET) within 12 months of diagnosis for stage I-III hormone receptor-positive BC (ET cohort=16220). We then simulated the potential increase in the proportion of patients receiving CTx and ET if proven patient-level disparity-reduction interventions were implemented across the state. Based on the literature, we assumed that the effects of these interventions in increasing treatment receipt would be same in the CTx and ET cohorts. We estimated the effect of this potential increase in CTx and ET receipt on 10-year overall survival using cohort-, race-, and treatment receipt-stratified Markov models. We report confidence bounds representing 95% of simulation results. Results: Over the 2004-2017 period, 72.9% and 70.8% of Black patients in our cohorts received CTx and ET, respectively. This was significantly lower than among nonBlack patients (p<.05). State-wide implementation of disparity reduction interventions could increase CTx and ET receipt among Black patients to 86.7% (80.9-92.5%) and 84.2% (78.5-89.9%), respectively. As a result, the racial 10-year survival gap would decrease from 9.4 to 8.1 (5.7-10.5) percentage points in the CTx cohort, and from 6.2 to 5.4 (4.0-6.7) percentage points in the ET cohort. Conclusions: Patient-level interventions can reduce disparities in guideline-concordant-treatment receipt. However, increases in treatment receipt alone would not be enough to close the racial survival gap, suggesting that, in isolation, patient-level interventions are unable to eliminate disparities. Action on the structural factors that disadvantage Black BC patients is needed. Our team is conducting community-engaged work to share and interpret these findings.
Disparities in clinical trial enrolment at a Canadian comprehensive cancer centre: A 15-year retrospective study.
Authors: Shapiro Gilla , Conti Rena M. , Santiago Anna , Pittman Tyler , Rodin Gary , Jones Jennifer M. , Cole Heather , Zeman Katherine , Sellmann Susanna , Rosenthal Meredith B. , Oza Amit M. , Rodin Danielle 
Published: June 2023

6550 Background: Disparities in clinical trials limit the generalizability of study findings and perpetuate disparities in treatment access and outcomes, but there is a paucity of data in the Canadian context. The objective of this study was to examine disparities in cancer clinical trial enrollment at a large, comprehensive Canadian cancer center. Methods: We conducted a retrospective cohort study of clinical trial enrollment among all newly diagnosed cancer patients (N=154,880) at the Princess Margaret Cancer Centre in Toronto, Canada (2006-2021). Multivariable Bayesian hierarchical logistic regression with random effect for most responsible physician was used to examine the correlates of clinical trial enrollment, comparing the population of enrolled and non-enrolled patients. Odds ratios were adjusted for patient variables (sex, age at diagnosis, language, geography, primary care provider), and census tract-level marginalization (residential instability, material deprivation, dependency, ethnic concentration), disease variables (cancer site and disease stage at diagnosis), and provider variables (most responsible physician (MRP), and MRP’s sex, language, medical training, and department). Results: Overall, 11.2% of patients enrolled (n=17,400) in a clinical trial, with 5-, 10-, and 15-year cumulative incidences of 12%, 15%, and 18%, respectively. Small, but significant differences were observed between enrollees and the overall patient population. Lower odds of enrollment were observed in patients who were female (adjusted odds ratio [AOR], 0.82; 95% confidence interval [CI], 0.78-0.86; p<.001), ≥65 years (AOR vs <40, 0.61; 95% CI, 0.56-0.65; p<.001), non-English language speakers (AOR vs English, 0.72; 95% CI, 0.67-0.77; p<.001), lived ≥250 km away from the cancer center (AOR vs <15km, 0.71; 95% CI, 0.62-0.80; p<.001), or lived in areas with greater material deprivation (AOR, 0.94; 95% CI, 0.93-0.96; p<.001) or higher ethnic concentration (AOR, 0.96; 95% CI, 0.94-0.98; p<.001). Greater odds of enrollment were found in patients with metastatic disease (AOR, 1.19; 95% CI, 1.13-1.25; p<.001) and in those with a primary care provider (AOR, 1.69; 95% CI, 1.55-1.85; p<.001). Conclusions: Disparities were observed in clinical trial enrollment, despite a publicly funded health care system. While broader prospective data collection efforts are critical to better understand the influence of patient, provider and system factors on clinical trial enrollment, these findings suggest the need for targeted strategies to increase diversity in clinical trial access.
Racial disparity in dose intensity of early-stage breast cancer chemotherapy.
Authors: Rosenzweig Margaret Q. , Mazanec Susan R , Brufsky Adam , Gordon Brittaney-Belle Elizabeth 
Published: June 2023

6556 Background: There are persistent, entrenched racial disparities noted in breast cancer outcomes. A basis for these disparities can be racial inequality for stage matched Black vs. White women in receiving early-stage breast cancer (ESBC) chemotherapy dose intensity of, at minimum, 85% or more of chemotherapy (historic gold standard) within prescribed timeframe. Our study measured dose reductions, early terminations, and overall dose intensity of ESBC chemotherapy in urban breast cancer centers and compared by race. Methods: Using a longitudinal, comparative descriptive design, treatment characteristics were measured in women receiving ESBC cancer chemotherapy in seven cancer centers in Western PA and Eastern Ohio. Dosing scheduled was calculated per patient chemotherapy prescription. Actual dose was measured as percentage of chemotherapy received / prescribed in “prescribed time,” meaning exact, ideal time to complete chemotherapy calculated from dose initiated without delay, dose reduction or early stoppage. The second measurement, “in any time,” measured chemotherapy completed over any course of time, incorporating delays and reductions. Results were dichotomized according to 85% of prescribed dose for both outcomes and compared by patient self-reported race (Black or White). Results: This study was conducted from August 2017 through June 2022. N=260 patients, race self-reported as 100 Black (38.5%) and 160 White (61.5%). Overall, n=36 (13.8%) had early termination of therapy. Early termination was more common for Black patients, 21%, vs 10% for White patients (p=.04). N=100 (38.3%) of all patients had some dose reduction, racially divided by 46.4% of Black patients vs. 34.3% of White patients, NS. By projected endpoint, Black patients received 77% (SD 24.1) of prescribed chemotherapy; White patients 86.7% (SD 16.6), p=.001. By “in any time” endpoint, Black patients received 86.5%, (SD 22.8) of prescribed therapy, White patients received 93.5% (SD 13.2), p=.002. By “in any time” measurement, 15% of White patients and 25% of Black patients did not receive the gold standard of 85% of prescribed chemotherapy. N= 7 of delays or terminations were due to disease progression, or poor response, and rarely, (n=4) to patient nonadherence. Largely, delays and early cessation were due to chemotherapy toxicity. Conclusions: Racial disparities in dose intensity and alterations of prescribed ESBC chemotherapy must be eliminated. Further examining the racial differences around dose delays and early chemotherapy termination, including racial barriers to patient- clinician communication around chemotherapy related toxicity, is essential to ensure equitable ESBC care and outcomes.
A quantitative synthesis of disparities in the inclusion of racial/ethnic minorities and older women in breast cancer trials.
Authors: Islam Mahnoor , Naqvi Syed Arsalan Ahmed , Bin Zafar Muhammad Daim , Ayaz Ahsan , Saleem Yusra , Khalid Atiqa , Wazir Muhammad Hisham Khan , Ijaz Hafsah , Giridhar Karthik , Yadav Siddhartha , Ernst Brenda , Riaz Irbaz Bin 
Published: June 2023

6557 Background: Trials that inadequately include underrepresented minority (URM) populations widen inequities in cancer care. We assessed reporting patterns, representation, and trends of URM representation in breast cancer (BC) trials. Methods: We analyzed all phase 2/3 trials for age disparity and trials recruiting from the US for racial/ethnic disparity amongst BC RCTs (1990-2021). Enrollment-incidence ratios (EIR), which compare trial proportions (TP) from age subgroups against global estimates of incidence in the corresponding age group (from Global Burden of Disease) and racial/ethnic subgroups against US-population-based incidence in the corresponding racial/ethnic group (from SEER 22), were calculated. Individual-trial EIRs were pooled using random-effects meta-analyses. EIRs of <0.80 indicated meaningful underrepresentation, while EIRs >1.20 indicated meaningful overrepresentation. Meta-regression was used to explore associations between key trial characteristics and EIR, and trends in EIR over the last three decades. Results: Of 842 global trials with 490,657 participants, 232 (27.6%) reported the number of participants in specific age strata and 144 (17.1%) reported outcomes by age. Only 60 trials recruited exclusively from the US. Of these, 41 (68.3%) reported race and 24 (40.0%) reported ethnicity, and 2 (3.3%) analyzed outcomes by race. Older adults aged ≥65 years (TP: 24.3%; EIR: 0.53 [95% CI: 0.47-0.60]) and Hispanic women (TP: 5.3%; 0.54; 0.40-0.75) were underrepresented across global trials and US-only trials respectively. Black women were significantly underrepresented in trials that led to FDA approval (0.38; 0.25-0.58) but not in US-only trials. Stratified analysis by BC subtype (with subtype-specific population incidence) showed underrepresentation of Black women in US-only trials for HER2+ BC (0.66; 0.47-0.93), Hispanic women in ER+ BC (0.42; 0.20-0.90), Asians in triple-negative BC (0.24; 0.11-0.53), and older women in HER2+ BC (0.35; 0.31-0.40) and triple-negative BC (0.36; 0.29-0.45). From 1990-2021, the representation of older women declined significantly (meta-regression coefficient for EIR: -0.4 per 10 years), while Black and Hispanic representation showed no significant change. Black (p = 0.02) and Hispanic representation (p = 0.05) worsened significantly in larger trials. Conclusions: Published reports of BC trials do not consistently report the inclusion of URM. Older and Hispanic women were consistently underrepresented, whereas Black women were underrepresented in large, practice-changing trials. [Table: see text]
Disparities in intensity of care at the end-of-life for patients with gastrointestinal cancer.
Authors: Rodriguez Gladys M. , Kapphahn Kris , Patel Manali I. 
Published: June 2023

6558 Background: Racial/ethnic minority patients experience disparities along the cancer continuum. Studies show that racial/ethnic minorities with cancer have higher rates of intensity of care at the end-of-life (EOL) compared to non-Hispanic Whites (NHW). Less is known whether disparities in intensity of care at EOL exist among racial/ethnic minority patients with a gastrointestinal (GI) cancer. Methods: Using the California Cancer Registry linked to hospital discharge data, we conducted a retrospective study of patients ≥18yrs with upper GI, pancreatic, or colorectal cancer who died from 2005-2018. We evaluated if race/ethnicity was associated with EOL intensity of care defined as hospital/ED visit or death, ICU, intubation, CPR & dialysis within 14-days of death. We used logistic regressions to calculate odds ratios adjusting for age, socioeconomic status (SES), insurance, geography, stage, comorbidities, and NCI-designated centers. Results: 189,837 patients with GI cancer died: 41,389 (21.8%) with upper GI, 46,554 (24.5%) with pancreatic & 101,894 (53.7%) with colorectal cancer. 118,995 (62.7%) were NHW, 14,146 (7.5%) Black, 33,802 (17.8%) Hispanic & 22,894 (12.1%) Asian/Pacific Islander (API). Median age was 74.6 yrs, 54.1% male, 85.9% lived in urban areas, 48.9% had Medicare, 16.1% had low SES & 35.7% had Stage 4. Black, Hispanic, and API patients compared to NHW had higher odds of intensity of care at EOL (Table). Conclusions: This study shows disparities in intensity of care at the EOL among racial/ethnic minorities with GI cancers. Solutions are urgently needed to reduce such disparities in care. [Table: see text]