Changes in Disparities in Stage of Breast Cancer Diagnosis in Pennsylvania After the Affordable Care Act

Abstract

Background: This study sought to determine if increased access to health insurance following the Affordable Care Act (ACA) resulted in an increased proportion of early-stage breast cancer diagnosis among women in Pennsylvania, particularly minorities, rural residents, and those of lower socioeconomic status. Materials and Methods: Data on 35,735 breast cancer cases among women 50-64 and 68-74 years of age in Pennsylvania between 2010 and 2016 were extracted from the Pennsylvania Cancer Registry and analyzed in 2019. Women 50-64 years of age were subdivided by race/ethnicity, area of residence, and socioeconomic status as measured by area deprivation index (ADI). We compared the proportions of early-stage breast cancer diagnosis pre-ACA (2010-2013) and post-ACA (2014-2016) for all women 50-64 years of age to all women 68-74 years of age. This comparison was also made between paired sociodemographic subgroups for women 50-64 years of age. Multivariable logistic regression models were constructed to assess how race, area of residence, ADI, and primary care physician (PCP) density interacted to impact breast cancer diagnosis post-ACA. Results: The proportion of early-stage breast cancer diagnosis increased by 1.71% post-ACA among women 50-64 years of age (p < 0.01), whereas women 68-74 years of age saw no change. Multivariable logistic regression analysis demonstrated that minority women had lower odds of early-stage breast cancer diagnosis pre-ACA, but not post-ACA, when controlling for ADI. Meanwhile, increased area-level socioeconomic advantage was associated with higher odds of being diagnosed with early-stage breast cancer pre- and post-ACA irrespective of controlling for race, area of residence, or PCP density. Conclusions: Enhanced access to health insurance under the ACA was associated with an increased proportion of early-stage breast cancer diagnosis in Pennsylvanian women 50-64 years of age and may have reduced racial, but not socioeconomic, disparities in breast cancer diagnosis.

Keywords: Affordable Care Act; breast cancer; health care disparities; screening and prevention.

FIG. 1.

Breast cancer case selection and exclusions. All breast cancer cases in Pennsylvania from 2010 to 2016 were queried using the Pennsylvania Cancer Registry.

FIG. 2.

Rate of early-stage breast cancer diagnosis. The unadjusted rate of early-stage breast cancer diagnosis pre-ACA (2010–2013) and post-ACA (2014–2016) is displayed for each subgroup. Subgroup analysis was performed only on women 50–64 years of age. p-Values apply to the difference in rate of early-stage breast cancer diagnosis pre- and post-ACA within each subgroup and are considered significant if <0.05. ACA, Affordable Care Act.