Trends in guideline-adherent fertility-sparing surgery for early-stage cervical cancer before and after the Affordable Care Act

Document Type

Journal Article

Publication Date

8-1-2020

Journal

Gynecologic Oncology

Volume

158

Issue

2

DOI

10.1016/j.ygyno.2020.05.027

Keywords

Cervical cancer; Early-stage; Health disparities; Insurance; Patient Protection and Affordable Care Act (ACA)

Abstract

© 2020 Elsevier Inc. Objective: To assess trends in guideline-adherent fertility-sparing surgery (GA-FSS) for early-stage cervical cancer relative to Patient Protection and Affordable Care Act (ACA) implementation. Methods: National Cancer Database patients treated for Stage IA1-IB1 cervical cancer from 2004 to 2016 were included. Multivariable logistic regression was used to determined trends in GA-FSS relative to the ACA and identify patient factors independently associated with GA-FSS. Results: Odds of GA-FSS increased in the post- compared to pre-ACA cohort (aOR = 1.65; 95%CI: 1.34–2.03). Decreasing age, Asian/Pacific Islander race, higher education and income levels, more recent treatment year, and lower clinical stage were independently associated with increased odds of receiving GA-FSS. In the pre- and post-ACA samples, decreasing age (per 1 year age increase; pre-ACA aOR = 0.87, 95%CI:0.85–0.90; post-ACA aOR = 0.85, 95%CI:0.83–0.87), higher education level (top vs. lowest education quartile; pre-ACA aOR = 2.08, 95%CI:1.19–3.65; post-ACA aOR = 2.00, 95%CI:1.43–2.80), and lower clinical stage (stages IA2 [pre-ACA aOR = 0.19, 95%CI:0.09–0.41; post-ACA aOR = 0.29, 95%CI:0.19–0.45] and IB1 [pre-ACA aOR = 0.06, 95%CI:0.06–0.16; post-ACA aOR = 0.16, 95%CI: 0.12–0.20] relative to stage IA1) were independently associated with increased odds of GA-FSS receipt. After the ACA, Asian/Pacific Islander race (aOR = 2.81, 95%CI: 1.81–4.36) and more recent treatment year (Spearman's ρ = 0.0348, p-value = 0.008) were also independently associated with increased odds of GA-FSS receipt. When adjusted for the pre- vs. post-ACA treatment periods, Medicaid patients were less likely to undergo GA-FSS than privately-insured patients (aOR = 1.65; 95%CI:1.34–2.03). Conclusions: Patients were more likely to receive GA-FSS post-ACA. Though the proportion of publicly-insured women increased after ACA implementation, women on Medicaid remained less likely to receive GA-FSS than women with private insurance.

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