1. Breast Cancer Detection, Treatment, and Survival in Medicare and Medicaid Insured Patients Cathy J. Bradley, Ph.D. Professor of Health Administration Co-leader, Cancer Prevention and Control, Massey Cancer Center

2. Disparities 25 Years Ago  Trends in racial differences in breast cancer mortality began in 1982  Detection, treatment, & mortality Mammography use Mammography use Sentinel lymph node biopsy Sentinel lymph node biopsy Radiation following BCS Radiation following BCS Surveillance following diagnosis & treatment Surveillance following diagnosis & treatment  Groups Racial/ethnic minorities Racial/ethnic minorities Low socioeconomic status Low socioeconomic status Age, comorbid conditions Age, comorbid conditions Appropriateness of careAppropriateness of care Uninsured Uninsured Medicaid insured Medicaid insured

3. Calendar vs. birth cohort trends  Calendar trends reflect effects of new medical interventions  Birth cohort trends reflect alterations in risk factors

4. Setting the stage: Calendar Period Trends in Breast Cancer Mortality Source: J Clin Onc 23;7836-7841, 2005.

5. Birth cohort trends in breast cancer mortality Source: J Clin Onc 23;7836-7841, 2005.

6. Trends in breast cancer mortality  Indicates that the majority of the difference is due to gaps in use of best treatment practices.

7. What happened?  1980s Mammography use became widespread Mammography use became widespread  1990s Adjuvant care (radiation, chemotherapy) became standard of care Adjuvant care (radiation, chemotherapy) became standard of care  1999 Sentinel lymph node biopsy to devise treatment plan Sentinel lymph node biopsy to devise treatment plan

8. Disparate groups  Racial/ethnic minorities  Uninsured  Publicly insured  Other Uncertain of benefits of detection and treatment Uncertain of benefits of detection and treatment  Complex relationship because racial/ethnic minorities are more likely to be uninsured or publicly insured.

9. African American women  Literature agrees Later stage at diagnosis Later stage at diagnosis Less likely to receive surgery and adjuvant care Less likely to receive surgery and adjuvant care Less likely to have SLNB Less likely to have SLNB  Controversy Equal treatment, controlling for stage, no survival differences (Bradley et al., 2002; Du et al., 2008). Equal treatment, controlling for stage, no survival differences (Bradley et al., 2002; Du et al., 2008). Some researchers find that survival disadvantages persist for African American women even after controlling for SES. Some researchers find that survival disadvantages persist for African American women even after controlling for SES.

10. Elderly dually eligible women (Low-income, publicly insured)  More likely to be diagnosed at later stage Nearly 3x more likely to be diagnosed at a later stage (Bradley et al., 2007). Nearly 3x more likely to be diagnosed at a later stage (Bradley et al., 2007).  Less likely to receive treatment – surgery, chemotherapy, radiation – within 6 months following diagnosis relative to women on Medicare.  Longer time from diagnosis to treatment  Shorter survival period (Bradley et al., 2002)

11. Uninsured  Disparities across all outcomes Stage Stage Treatment Treatment Mortality Mortality

12. Disparities NOW  No decrease in racial disparities in treatment from 1992 to 2002 (Gross et al., 2008).  Dually eligible women are less likely to be treated than Medicare only women.  Wealthy women are more likely to have a mammogram, even when their life expectancy is short (Williams et al., 2008).  Regardless of outcome or controls for patient characteristics, differences between insured and uninsured persist.

13. Implications  Small amount of gap can be closed by better defining when screening & treatment is beneficial (efficiency).  Provide better insurance coverage may close the gap further.  However, disparities in publicly insured still persist. Patient education Patient education Physician/patient communication Physician/patient communication Shift to a preventive model Shift to a preventive model

14. Challenges  Provision of technology and treatment advancements to low-income and racial/ethnic minorities.  Absence of health insurance.  Assessing when treatment can benefit somewhat high risk patients (older, patients with comorbid conditions).