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IMPORTANCE: Patients who are uninsured and belong to racial and ethnic minority groups or have low socioeconomic status have suboptimal access to health care, likely affecting outcomes. The association of the Affordable Care Act’s Medicaid expansion with survival among patients with metastatic breast cancer is unknown. OBJECTIVE: To examine the association between Medicaid expansion and mortality disparity among patients with de novo stage IV breast cancer. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional, population-based study of survival using Cox proportional hazards regression and difference-in-difference (DID) analysis of data from the National Cancer Database and patients diagnosed as having de novo stage IV breast cancer between January 1, 2010, and December 31, 2016, residing in states that underwent Medicaid expansion on January 1, 2014. The preexpansion period was January 1, 2010, to December 31, 2013; the postexpansion period was January 1, 2014, to December 31, 2016. Data were analyzed between September 4, 2020, and November 16, 2021. EXPOSURES: Comparison of survival improvement between patients of racial and ethnic minority groups and White patients in the preexpansion and postexpansion periods. Because of small numbers in the specific racial and ethnic minority groups, these patients were combined into 1 category for comparisons. MAIN OUTCOMES AND MEASURES: Overall survival (OS) and 2-year mortality rate. RESULTS: Among 9322 patients included (mean [SD] age, 55 [7] years), 5077 were diagnosed in the preexpansion and 4245 in the postexpansion period. The racial and ethnic minority group comprised 2545 (27.3%), which included 500 (5.4%) Hispanic (any race), 1515 (16.3%) non-Hispanic Black, and 530 (5.7%) non-Hispanic other including 25 (0.3%) American Indian or Alaska Native, 357 (3.8%) Asian or Pacific Islander, and 148 (1.6%) unknown, and 6777 (72.7%) were in the White patient group. In the preexpansion period, White patients had increased OS compared with patients of racial and ethnic minority groups (adjusted hazard ratio [aHR], 1.22; 95% CI, 1.10-1.35); this difference was not observed in the postexpansion period (aHR, 0.96; 95% CI, 0.86-1.08). A reduction in 2-year mortality was observed between the preexpansion and postexpansion periods (32.2% vs 26.0%). The adjusted 2-year mortality decreased from 40.6% to 36.3% among White patients and from 45.6% to 35.8% among patients of racial and ethnic minority groups (adjusted DID, −5.5%; 95% CI, −9.5 to −1.6; P = .006). Among patients in the lowest income quartile (n = 1510), patients of racial and ethnic minority groups had an increased risk of death in the preexpansion period (aHR, 1.28; 95% CI, 1.01-1.61) but lower risk in the postexpansion period (aHR, 0.75; 95% CI, 0.59-0.95). In this subset of patients, those of racial and ethnic minority groups had a greater reduction in 2-year mortality compared with White patients (adjusted DID, −12.8%; 95% CI, −22.2 to −3.5; P = .007). CONCLUSIONS AND RELEVANCE: In this cross-sectional study, survival differences observed between patients of racial and ethnic minority groups and White patients in the preexpansion period were no longer present in the postexpansion period. A greater reduction in 2-year mortality was observed among patients of racial and ethnic minority groups compared with White patients. These results suggest that policies aimed at improving equity and increasing access to health care may reduce racial and ethnic disparities in breast cancer outcomes.

Ashley J Housten,1 Catalina Malinowski,2 Edna Paredes,3 Cassandra L Harris,3 Lorna H McNeill,3 Mariana Chavez-MacGregor2,4 1Division of Public Health Sciences, Washington University School of Medicine, St Louis, MO, USA; 2Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; 3Department of Health Disparities Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; 4Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USACorrespondence: Mariana Chavez-MacGregor, 1400 Pressler St Unit 1444, Houston, TX, 77030, USA, Tel +1 713 563 0020, Email MChavez1@mdanderson.orgPurpose: (Neo) adjuvant chemotherapy decreases the risk of recurrence and improves overall survival among breast cancer patients; however, delays in chemotherapy initiation are associated with adverse health outcomes. The causes of delay are complex and include interrelated social, economic, cultural, environmental, and health system factors. Project Start was a qualitative study designed to assess and identify the multilevel factors contributing to the barriers and facilitators of initiating chemotherapy.Patients and Methods: Women diagnosed with primary invasive breast cancer who experienced ≥ 60 day delay in (neo) adjuvant chemotherapy initiation were included. Participants completed semi-structured interviews exploring barriers and facilitators to starting chemotherapy. Interviews were transcribed and coded to identify themes using the Sort and Sift, Think and Shift analytic approach. This analysis included thorough examination of the data by advancing through iterative analytic phases to identify core topics within and across transcripts.Results: We enrolled (N=22) participants with median age at diagnosis 53.5 years (range 27– 70) who identified as Latina (n=8), Black (n=5), and non-Latina White (n=9). Participants described a common chemotherapy initiation process reflecting their unique needs as they transitioned through four stages: 1) receiving diagnosis and treatment recommendations; 2) processing treatment options; 3) “Flipping the Switch”; and 4) activating treatment and engaging in care. Limited explicit insight into their chemotherapy delay was expressed. Engagement across the self-, family-, community-, and medical-realms revealed interlinked and pivotal sources of support that helped participants navigate toward initiating chemotherapy. Specifically, the overarching themes included logistical, emotional, financial, and social sources of support and the relationship of these sources of support to participants’ perceived self-efficacy to move toward initiating treatment.Conclusion: Activating women to be engaged in the treatment process across multiple levels appeared to facilitate initiating chemotherapy. Multilevel interventions that engage the patient, family, community, and medical team may support the initiation of timely chemotherapy.Keywords: breast cancer, care delivery, chemotherapy, treatment delay, oncology, qualitative, patient perspectives

Background Medicaid expansion under the Affordable Care Act extends eligibility for participating states and has been associated with improved outcomes by facilitating access to care. Delayed initiation of adjuvant chemotherapy is associated with worse outcomes among patients with early-stage breast cancer (BC). The impact of Medicaid expansion in narrowing delays by race and ethnicity has not been studied, to our knowledge. Methods This was a population-based study using the National Cancer Database. Patients diagnosed with primary early-stage BC between 2007 and 2017 residing in states that underwent Medicaid expansion in January 2014 were included. Time to chemotherapy initiation and proportion of patients experiencing chemotherapy delays (>60 days) were evaluated using difference-in-difference and Cox proportional hazards models in preexpansion and postexpansion periods according to race and ethnicity. Results A total 100 643 patients were included (63 313 preexpansion and 37 330 postexpansion). After Medicaid expansion, the proportion of patients experiencing chemotherapy initiation delay decreased from 23.4% to 19.4%. The absolute decrease was 3.2, 5.3, 6.4, and 4.8 percentage points (ppt) for Black, Hispanic, White, and Other patients. Compared with White patients, statistically significant adjusted difference-in-differences were observed for Black (−2.1 ppt, 95% confidence interval [CI] = −3.7% to −0.5%) and Hispanic patients (−3.2 ppt, 95% CI = −5.6% to −0.9%). Statistically significant reductions in time to chemotherapy between expansion periods were observed among White patients (adjusted hazard ratio = .11, 95% CI = 1.09 to 1.12) and those belonging to racialized groups (adjusted hazard ratio = 1.14, 95% CI = 1.11 to 1.17). Conclusions Among patients with early-stage BC, Medicaid expansion was associated with a reduction in racial disparities by decreasing the gap in the proportion of Black and Hispanic patients experiencing delays in adjuvant chemotherapy initiation.

Among Hispanic women, breast cancer is the most common cancer accounting for close to 30% of the total cancer cases. It is estimated that in 2018 alone, 24,000 Hispanics were diagnosed with invasive breast cancer. Of significant importance is that breast cancer is the leading cause of cancer death (16%) among Hispanic women, with over 3000 patients dying in 2018 secondary to this disease.Despite the decrease in breast cancer mortality rates seen in recent years, the magnitude of that decrease among Hispanics is lower compared to the decrease seen among non-Hispanic White women (1.1% per year vs 1.8% per year). Potential contributing factors associated with this phenomenon include the fact that Hispanics are more likely to be diagnosed with more advanced stages and to have tumors with aggressive biology. In addition, sociodemographic factors and difficulty accessing medical care are likely to play an important role. It has been described that Hispanic women are less likely that non-Hispanic Whites to receive appropriate and timely breast cancer treatment. In this chapter, we will review the complexities of breast cancer diagnosis and treatment. We will briefly review some of the challenges in cancer care delivery that Hispanics experience and will review data describing the detrimental impact that treatment delays can have among minorities and some of the unique challenges that Hispanics experience.

Catalina Malinowski,1 Edna Paredes,2 Ashley J Housten,3 Mariana Chavez-MacGregor2,4 1Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; 2Department of Health Disparities Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; 3Division of Public Health Sciences, Washington University School of Medicine, St Louis, MO, USA; 4Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USACorrespondence: Mariana Chavez-MacGregor, 1400 Pressler St Unit 1444, Houston, TX, 77030, USA, Tel +1 713 563 0020, Email MChavez1@mdanderson.orgPurpose: Although the association between delays in (neo)adjuvant chemotherapy initiation and adverse outcomes is well-documented, patient perspective regarding the lived experience among those with breast cancer delay is sparse. Project Start was a qualitative study designed to assess and identify the multilevel factors contributing to the barriers and facilitators of initiating chemotherapy. This report explores specific responses where patients with breast cancer provide insight and advice for newly diagnosed women on preparing for chemotherapy initiation and informs potential interventions to facilitate timely chemotherapy initiation.Patients and Methods: Women diagnosed with primary invasive breast cancer who experienced a ≥ 60-day delay in (neo)adjuvant chemotherapy initiation were included. Participants completed semi-structured interviews exploring barriers and facilitators to starting chemotherapy. Interviews were transcribed and coded to identify themes.Results: We enrolled (N = 22) participants with a median age at diagnosis of 53.5 years (range 27– 70) who identified as Latina (n = 8), Black (n = 5), and non-Latina White (n = 9). Our participants indicated that engaging their medical teams and seeking support earlier were essential to initiate their treatment journeys. They emphasized being proactive and thorough in all aspects of their journey, particularly in processing medical recommendations, communicating with medical personnel, and identifying areas of need. Although explicit insight into chemotherapy delay was rare, participants expressed the importance of beginning treatment promptly. They shared advice on acquiring support (eg, financial, emotional, logistical, spiritual) and suggested connecting with breast cancer survivors to overcome the complex challenges of cancer care.Conclusion: Patient perspectives regarding barriers and treatment facilitators help provide insight into the lived experience of cancer care journeys that can inform interventions to improve patient support and outcomes. We are using these results to develop a pilot study to test the acceptability and feasibility of a culturally tailored patient navigation intervention to increase self-efficacy and avoid treatment delays.Keywords: breast cancer, care delivery, chemotherapy, treatment delay, oncology, qualitative, patient perspectives