ACA Tied to Lower Rates of High-Risk Prostate Cancer

WASHINGTON -- States that expanded Medicaid in 2014 following passage of the Affordable Care Act (ACA) saw reduced rates of high-risk prostate cancer and men presenting with high prostate-specific antigen (PSA) levels at diagnosis, a difference-in-difference analysis indicated.

Examining rates of newly diagnosed high-risk localized prostate cancer in 2012-2013 with rates from 2015-2016, there was a 1.3% reduction for men living in states that expanded the low-income insurance program (95% CI -2.3% to -0.3%, P=0.015), reported Adam Weiner, MD, of Northwestern University Feinberg School of Medicine in Chicago.

"We didn't see a change in metastatic disease at diagnosis, but we're also not very surprised by that," Weiner told MedPage Today. "It may be several years down the road that we'll see a change in metastatic disease at diagnosis, but the positive thing that we're seeing here is a decline in high-risk PSA, which is probably going to be a forecast for better outcomes for these patients."

According to the findings, which were presented during a poster session at the Society of Urologic Oncology annual meeting, there was a 2.3% reduction in the rate of men presenting with PSA levels greater than 20 ng/mL at diagnosis in expansion versus non-expansion states (95% CI -3.2% to -1.4%, P<0.001).

"We chose this cutoff because even if men don't have metastatic disease, if they have a PSA greater than 20 they're at a very high risk for recurring even if they get the proper treatment," Weiner said.

For black men in particular, there was a 3.1% reduction in high PSA levels for expansion states (95% CI -5.3% to -1.0%, P=0.005), though no difference was seen with regard to rates of high-risk localized disease.

Men without insurance typically present with later-stage prostate cancer and have worse outcomes than the insured.

"One of the most obvious ways to deal with that is to make huge policy changes that affect everyone and improve healthcare access," said Weiner.

He noted that Medicaid expansion has been associated with positive effects across genitourinary cancers.

"We're likely going to see some stage migrations, and we're hopefully going to see some changes in timely care," he said. "Overall, I think it's improving access to care for a lot of our patients."

In 2014, about 20 states expanded Medicaid and about 20 did not, and this allowed the researchers to perform a difference-in-difference analysis between these two groups of states, while controlling for changes in PSA screening recommendations and other shifts in practice or disease trends during this time.

They compared newly diagnosed prostate cancer cases recorded in the National Cancer Database before (2012-2013) and after (2015-2016) Medicaid expansion. Over these years, 65,954 men in non-expansion states and 56,370 men from expansion states were diagnosed with prostate cancer.

There were no measurable differences between expansion and non-expansion states when it came to rates of low- or intermediate-risk disease at diagnosis -- these rates remained relatively flat across the 5-year period. For metastatic disease, rates increased slightly for men in both groups of states.

Median age at diagnosis across all states was 59. In expansion states, 72% of the men were white and 17% were black. In non-expansion states, these rates were 67% and 25%, respectively.