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Oncology

Research

Treating cervical cancer: Breast and Cervical Cancer Prevention and Treatment Act patients
Li-Nien Chien, PhD; E. Kathleen Adams, PhD; Lisa C. Flowers, MD
OBJECTIVE: To investigate cervical cancer treatment of patients enRESULTS: Preinvasive disease cases with cervical intraepithelial neo-

rolled under the Breast and Cervical Cancer Prevention and Treatment Act in Georgia. STUDY DESIGN: Georgia Comprehensive Cancer Registry and Medicaid enrollment/claims were used to identify enrollees with preinvasive disease (n 1149) and invasive cervical cancer (n 444). Logistic regressions were used to estimate factors associated with the odds of receiving: (1) cancer workup, (2) precancerous procedure, (3) surgery, (4) radiation, and (5) chemotherapy.

plasia 3, in situ, a comorbidity or without a Commission on Cancer approved hospital nearby were more likely to receive surgery. Among invasive cases, later stage was associated with higher odds of receiving radiation or chemotherapy. Black patients were less likely to have surgery than white patients regardless of preinvasive (P .01) or invasive status (P .05). CONCLUSION: Treatment patterns among Georgia Medicaid cases appear appropriate to stage but 18% with invasive cervical cancer received no cancer treatment, although Medicaid enrolled.

Cite this article as: Chien L-N, Adams EK, Flowers LC. Treating cervical cancer: Breast and Cervical Cancer Prevention and Treatment Act patients. Am J Obstet Gynecol 2011;204:533.e1-8.

B ACKGROUND AND O BJECTIVE

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP), funded by the Centers for Disease Control and Prevention, has provided screening and diagnostic follow-up for low-income uninsured women since 1990. The Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) of 2000 gives states the option of offering women in the NBCCEDP access to treatment through Medicaid. Although BCCPTA mandated that women be screened by the NBCCEDP, states could extend eligibility to women screened by nonNBCCEDP providers. Women are continuously eligible for BCCPTA as long as they are considered to be under cancer treatment by their physicians. BCCPTA implementation in Georgia led to an increase in Medicaid enrollment of 2-3 more women with these cancers in a given month and shortened
From the Department of Health Policy and Management (Drs Chien and Adams), Rollins School of Public Health, and the Department of Gynecology and Obstetrics (Dr Flowers), Emory University, Atlanta, GA.
Supported by Grant no. RSGT-05-004-01CPHPS from the American Cancer Society. 0002-9378/free 2011 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2011.01.033

the enrollment process by 7-8 months. Hence, breast cancer patients can enroll and potentially start treatment while still at an early stage of disease. This could, in turn, lead to better outcomes and longer survival. The simpler recertication process under BCCPTA created both stable insurance coverage and connection with the participants health care providers, resulting in a 50% decline in the rates of disenrollment from Medicaid for both cancers after BCCPTA. The goal of BCCPTA is to provide Medicaid coverage to assure high-quality treatment. It is important to understand the cancer treatment pattern of patients diagnosed with preinvasive disease and invasive cervical cancer under BCCPTA.

did not include preinvasive (CIN 2 and 3, in situ) cervical cases; therefore, we identied those cases as women who were ever enrolled under the BCCPTA eligibility category but were not invasive cervical or breast cancer cases in the GCCR.

R ESULTS
The Figure shows the types of cervical cancer treatment that patients received within 2 years of Medicaid enrollment. For patients with preinvasive cervical disease, 56% had any cancer workup, 75% had any precancerous procedure, and 21% had a simple hysterectomy. For patients with invasive cervical cancer, 85% had any cancer workup, 34% had any invasive surgery, 62% had any radiation, and 54% had any chemotherapy. Among preinvasive cervical patients, 75% had precancerous procedures, 8% had simple hysterectomy, and 13% had both treatments. Less than 1% of these patients received only radiation and/or chemotherapy and 4% received no treatment for their disease. For invasive cases, overall, 15% had invasive surgery, 51% had radiation and/or chemotherapy, 17% had both, and 18% received no cancer treatment. Among invasive cases, non-Hispanic black patients were signicantly less likely to have invasive surgery after control for the other covariates (P .05). Later stage 533

M ATERIALS AND M ETHODS

The major datasets used were the Georgia Cancer Comprehensive Registry (GCCR), Medicaid enrollment, and claims les. County data were from the Area Resource File, Commission on Cancer, and Consolidated Analysis Center, Incorporated. Incident cervical cancer cases in the GCCR from July 1, 2001, through Dec. 31, 2004, were linked to the Medicaid enrollment le using patients encrypted Social Security numbers for those identied with a primary site of cancer of the cervix (local stage and beyond). GCCR

JUNE 2011 American Journal of Obstetrics & Gynecology

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Oncology

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tient navigation intervention might be helpful as it has been shown to improve mammography screening rates for lowincome minority populations in several studies. Devoting nancial resources to patient navigation for cervical cancer, as with breast cancer, may improve patient follow-up in this vulnerable population.

Cervical treatment of patients with preinvasive and invasive cervical cancer under Medicaid

CLINICAL IMPLICATIONS

Chien. Cervical cancer treatment under BCCPTA. Am J Obstet Gynecol 2011.

was associated with higher odds of radiation or chemotherapy, but not surgery. BCCPTA women were no different in terms of receiving invasive surgery, radiation, or chemotherapy than other eligibility groups, whereas disabled patients were less likely to undergo surgery.

C OMMENT
BCCPTA is a policy approach for addressing the challenges of the uninsured facing serious illness by providing cancer treatment through a special Medicaid eligibility option. Further analysis indicated that a leading reason for the lack of treatment was disenrollment from Medicaid. Of those patients who were

continuously enrolled in Medicaid over our 2-year study period, only 6% had no follow-up treatment. We were unable to control for nonclinical factors affecting treatment, such as patient refusal because of individual beliefs or preferences. Lack of insurance coverage is traditionally seen as the main reason for patients not to receive timely and appropriate treatment. However, this study found that obtaining insurance through BCCPTA is only part of the solution to help previously uninsured low-income women diagnosed with those cancers to receive treatment. To increase the rate of treatment in this vulnerable group, pa-

Expanding Medicaid for uninsured low-income patients is a viable policy for increasing access to care for cervical cancer patients. The receipt of clinically appropriate care while enrolled in Medicaid can prevent new cases as well as improve the prognosis and health outcomes for those already diagnosed with cervical cancer. Evidence that preinvasive cervical patients living in a county with a Commission on Cancer approved hospital were likely to receive nonsurgical treatment and less likely to have a hysterectomy may indicate that the presence of specialists and oncologists associated with this type of hospital provides more alternative treatment options. The effect of disenrollment on the receipt of any treatment indicates that policy makers and providers should work to retain women in Medicaid until they have completed their treatment regimens. Patients with invasive cervical cancer who received no treatment should be further investigated to see whether patient navigation is a viable tool to address this issue. f

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