Timing of Medicaid Enrollment, Late-Stage Breast Cancer Diagnosis, Treatment Delays, and Mortality

Abstract

Background: Disrupted and delayed Medicaid coverage has been consistently associated with lower rates of cancer screening and early-stage cancer diagnosis compared with continuous coverage. However, the relationships between Medicaid coverage timing, breast cancer treatment delays, and survival are less clear.

Methods: Using the linked Missouri Cancer Registry-Medicaid claims data, we identified 4583 women diagnosed with breast cancer between 2007 and 2016. We used logistic regression to estimate odds ratios (ORs) of late-stage diagnosis and treatment delays for prediagnosis (>30 days, >90 days, and >1 year before diagnosis) vs peridiagnosis enrollment. Cox proportional hazards models were used to estimate the hazard ratio (HR) of breast cancer-specific mortality for pre- vs postdiagnosis enrollment.

Results: Patients enrolled in Medicaid more than 30 days before diagnosis were less likely to be diagnosed at a late stage compared with those enrolled in Medicaid peridiagnosis (OR = 0.69, 95% confidence interval [CI] = 0.60 to 0.79). This result persisted using enrollment 90-day (OR = 0.64, 95% CI = 0.56 to 0.74) and 1-year thresholds (OR = 0.55, 95% CI = 0.47 to 0.65). We did not observe a difference in the likelihood of treatment delays between the 2 groups. After adjustment for sociodemographic factors, there was no statistically significant difference in the risk of breast cancer mortality for patients enrolled more than 30 days prediagnosis relative to patients enrolled peridiagnosis (HR = 0.98, 95% CI = 0.83 to 1.14), but a lower risk was observed for patients enrolled prediagnosis when using 90 days (HR = 0.85, 95% CI = 0.72 to 0.999) or 1 year (HR = 0.79, 95% CI = 0.66 to 0.96) as the threshold.

Conclusions: Women with breast cancer who enroll in Medicaid earlier may benefit from earlier diagnoses, but only longer-term enrollment may have survival benefits.

Figure 1.

Odds ratios (ORs) of late-stage diagnosis in women with breast cancer enrolled in Medicaid before diagnosis compared with those enrolled peridiagnosis. Late-stage diagnosis included stages III-IV. The analysis was adjusted for age, race, marital status, and socioeconomic characteristics of census tracts. CI = confidence interval.

Figure 2.

Odds ratios (ORs) of treatment delays in women with breast cancer enrolled in Medicaid before diagnosis compared with those enrolled peridiagnosis. Treatment delays were defined as more than 60 days from diagnosis to surgery, radiation therapy, chemotherapy, or hormone therapy. The analysis was adjusted for age, race, marital status, socioeconomic characteristics of census tracts, tumor stage, size, grade, and hormone receptor subtypes. CI = confidence interval.

Figure 3.

Hazard ratios (HRs) of breast cancer–specific mortality in women with breast cancer enrolled in Medicaid before diagnosis compared with those enrolled peridiagnosis. ^aThe analysis was not adjusted for any covariates. ^bThe analysis was adjusted for age, race, marital status, and socioeconomic characteristics of census tracts. ^cThe analysis was further adjusted for tumor stage, size, grade, and hormone receptor subtypes. CI = confidence interval.