Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Introduction: The American Society for Clinical Oncology and the National Comprehensive Cancer Network recommend early and integrated palliative care (PC) interventions for advanced-stage cancers. Medicaid expansion, a component of the Affordable Care Act, has increased access to cancer care services across forty states for patients with Medicaid insurance. A recent study demonstrated Medicaid expansion states were associated with increased access to PC in patients with advanced-stage cancers. However, the rate with which patients with stage IV oral cavity squamous cell carcinoma (OCSCC) receive PC as part of their oncologic care is unknown. We sought to understand the utilization of PC for patients with stage IV OCSCC in Medicaid expansion states compared to those patients in states without Medicaid expansion.
Methods: The National Cancer Database was queried for patients with stage IV OCSCC from 2004-2017. Cases were excluded if receipt of palliative care treatment, insurance status, or Medicaid expansion status was unknown. Expanded (EXP) states were those that implemented Medicaid expansion in 2017 or earlier. Patients in 2EXP states were categorized as either pre-expansion (pre-EXP) or post-expansion (post-EXP) according to state-specific implementation. Patients in non-expanded states (NEXP) were categorized as either diagnosed before 2014 (pre-NEXP) or during/after 2014 (post-NEXP). Multivariable logistic regression was performed to compare receipt of PC among pre-EXP and post-EXP patients, and separately among post-EXP and post-NEXP cases.
Results: There were 15,280 patients who met inclusion criteria. Comparing pre-EXP and post-EXP cases, there was a trend towards increased receipt of PC among post-EXP cases, but this did not reach statistical significance (OR 1.17, 95% CI 0.92-1.47). Among pre-EXP and post-EXP cases, black patients were more likely than white patients (OR 1.36, 95% CI 1.00-1.84), higher income quartiles were less likely than the lowest quartile (OR 0.62, 95% CI 0.44-0.89; OR 0.66, 95% CI 0.46-0.94), gum and vestibule cancers were less likely than tongue cancer (OR 0.47, 95% CI 0.28-0.77), and patients with private insurance were less likely than patients with no insurance (OR 0.48, 95% CI 0.32-0.72) to receive PC. Among post-EXP and post-NEXP cases, expansion status did not significantly predict receipt of palliative care. In this cohort, gum and vestibule cancers were less likely than tongue cancers to receive PC (OR 0.55, 95% CI 0.33-0.92).
Conclusion: There was no significant association of patients with stage IV OCSCC in states with Medicaid expansion and receipt of PC compared to non-expanded states. However, results among patients in pre-EXP and post-EXP states suggest increased PC use among more vulnerable and disadvantaged patient groups. Further analysis on receipt of PC in vulnerable patient populations with advanced-stage cancer is warranted.