Medicaid and Medicare beneficiaries are more likely to die from breast cancer or stop treatment early than those women who are on commercial insurance based on the results of a study of 10,000 women presented on December 12, at the San Antonio Breast Cancer Symposium. The research found that Medicaid and Medicare beneficiaries are also less likely to participate in clinical trials. Physicians and policy-makers should understand that having a more social determinant of health data can lead to better outcomes.
Insurance: an Influence on Life and Death
The study reveals that at least among the sample population, “insurance appears to be a powerful determinant of clinical trial outcomes,” reported Samilia Obeng-Gyasi, MD, a breast surgical oncologist at Ohio State University.
A retrospective study of nearly 9,800 women with breast cancer who participated in randomized clinical trials found that women with government insurance were much less likely to participate in clinical trials compared to their privately insured counterparts. The few women covered by government plans were more likely to stop treatment early and had lower survival. The study was conducted by the ECOG-ACRIN Cancer Research Group (ECOG-ACRIN) with funding from the National Cancer Institute.
Study lead Dr. Obeng-Gyasi and team reviewed data from women who participated in two large ECOG-ACRIN trials testing chemotherapy treatments. Study E1199 enrolled participants from 1999 to 2002 and study E5013 enrolled participants between 2007 and 2011. The team evaluated each participant’s insurance coverage and neighborhood socioeconomic status at the time they entered the trial in the hopes of determining if either status affected the women’s clinical outcomes later on.
In these studies, the majority of participants (85%) had commercial insurance—only 13% participated in government insurance programs (e.g., Medicare or Medicaid).
Government Insured Participants Drop
Patients with government insurance were less likely to complete treatment compared to their privately insured counterparts. One out of every four government-insured patients did not complete treatment in E1199 versus one out of every seven privately insured women. In E5103, approximately one out of every two government-insured patients did not complete therapy compared to one out of every three privately insured patients. Completion of the trial and survival outcomes were each controlled for disease severity, age, and other patient characteristics that could influence the participant’s outcomes.
Government Insured Patients at Greater Risk
The government-insured patients also had a higher risk of dying compared to their privately insured counterparts. In E1199, the risk of death increased by one half. For those in E5103, the risk increased by one-third. The researchers determined the neighborhood socioeconomic status of each participant by linking their zip code to county-level data on occupation, income, poverty, wealth, education, and crowding. There was no association between neighborhood socioeconomic status and trial completion or survival.
Principal Investigator: Insurance Type a Powerful Determinant of Clinical Trial Outcomes
“Insurance appears to be a powerful determinant of clinical trial outcomes,” said Dr. Obeng-Gyasi. “With continued changes to insurance at the federal and state levels, physicians and policy-makers would benefit from having more data such as what we produced in our study. Right now, most clinical trials do not collect data on social determinants of health. If they did, the information could lead us to better understand the interaction of insurance status and many other factors on the clinical outcomes of clinical trial participants.”
About ECOG-ACRIN Cancer Research Group
The ECOG-ACRIN Cancer Research Group (ECOG-ACRIN) is a membership-based scientific organization that designs and conducts cancer research involving adults who have or are at risk of developing cancer. ECOG-ACRIN comprises nearly 1100 member institutions in the United States and around the world. Approximately 12,000 physicians, translational scientists, and associated research professionals from the member institutions are involved in Group research, which is organized into three scientific programs: Cancer Control and Outcomes, Therapeutic Studies, and Biomarker Sciences. ECOG-ACRIN is supported primarily through National Cancer Institute research grant funding, but also receives funding from private sector organizations through philanthropy and collaborations. Its headquarters are in Philadelphia, Pa.
Dr. Obeng-Gyasi, MD Ohio State University
Call to Action: These findings are quite disturbing. With nearly 150 million insured under Medicaid and Medicare (and over half being women) and a percentage of that population at risk for breast cancer, the number of total women at risk is shockingly high.