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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.

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.

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

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

255 Background: Although the association between delays in (neo)adjuvant chemotherapy initiation and adverse outcomes is well-documented, research into what those with breast cancer experience during their delay is sparse. This information can provide insight for newly diagnosed women on preparing for chemotherapy initiation and inform potential interventions to facilitate chemotherapy initiation. This study aimed to assess and identify the multilevel factors contributing to the barriers and facilitators of initiating chemotherapy. We present a qualitative exploration of patient shared experiences navigating the cancer care journey from breast cancer diagnosis to treatment activation. Methods: In this qualitative study, we included English or Spanish-speaking women diagnosed with primary invasive breast cancer who experienced chemotherapy initiation delay. We conducted semi-structured interviews exploring perceptions about individual, community, and system-level barriers and facilitators contributing to starting chemotherapy. We prompted participants to reflect on their personal experience navigating their cancer journeys from initial diagnosis to treatment initiation. Interviews were audio-recorded, transcribed verbatim, and coded using the Sort and Sift, Think and Shift qualitative approach to identify concepts and themes within and across transcripts. Results: Twenty-two participants completed semi-structured interviews and questionnaires (range 27-70 years); they identified as Latina (n = 8), Black (n = 5), and non-Latina White (n = 9). Our participants thought that engaging their medical teams and seeking support earlier was essential for 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 (e.g., financial, emotional, logistical, spiritual) and suggested connecting with breast cancer survivors to overcome the complex challenges of cancer care. Conclusions: Patients outlined the benefit of attaining support outside of their medical teams to overcome barriers and initiate treatment promptly. Family, friends, and connecting with breast cancer survivors were vital in achieving activation. Patient perspectives regarding barriers and treatment facilitators are an essential insight into cancer care journeys that can inform interventions to support patients and improve outcomes. We are using these results to develop a pilot study, to test the acceptability and feasibility of a culturally relevant patient navigation intervention to increase self-efficacy and avoid treatment delays.

247 Background: (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 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 chemotherapy initiation. Methods: English or Spanish-speaking women, ≥18 years, diagnosed with primary invasive breast cancer experiencing (neo)-adjuvant chemotherapy initiation delay ( ≥60 days) were included. Participants completed semi-structured interviews designed to explore perceptions about individual, community, and system-level barriers and facilitators contributing to chemotherapy initiation. Interviews were audio-recorded, transcribed verbatim, and coded using the Sort and Sift, Think and Shift qualitative approach to identify concepts and themes within and across transcripts. To supplement qualitative data, sociodemographic data and health literacy/numeracy, physician trust, and social support questionnaires were obtained. Results: Participants (n = 22) identified as: Latina (n = 8); Black (n = 5); and non-Latina White (n = 9). While the interview guide included questions addressing chemotherapy delays, explicit insight into chemotherapy delay was rare. Participants described barriers and facilitators at the patient, family, medical, and community levels. Barriers at the patient level included patient’s hesitancy to initiate chemo due to shock, fear, and denial. Within the family level, we learned of participant’s family roles (e.g., caregiving, income), treatment costs, and the need for emotional support (e.g., not shutting family members out). Participants sought out and relied heavily on support from their communities (e.g., churches, other patients, survivors). Patients described their reliance on the medical team for information, the trust needed to navigate their treatment process, and the challenge of managing information associated with their treatment. Participants described the importance of self-efficacy to take an active role in treatment. Conclusions: Project Start is informing the design of a pilot study aimed to test the acceptability and feasibility of a navigation intervention. Using facilitators and barriers identified from Project Start, we are developing a checklist that will serve as a tool to identify the support each patient needs. Once areas of need are identified, appropriate referrals will be made in a personalized and culturally sensitive way with the goal of increasing self-efficacy and activating patients to avoid treatment delays.

6525 Background: Inadequate access to healthcare services is associated with worse outcomes. Disparities in access to cancer care are more frequently seen among racial/ethnic minorities, uninsured patients, and those with low socioeconomic status. A provision in the Affordable Care Act called for expansion of Medicaid eligibility in order to cover more low-income Americans. In this study, we evaluate the impact of Medicaid expansion in 2-year mortality among metastatic BC patients according to race. Methods: Women (aged 40-64) diagnosed with metastatic BC (stage IV de novo) between 01/01/2010 and 12/31/2015 and residing in states that underwent Medicaid expansion in 01/2014 were identified in the National Cancer Database. For comparison purposes, 2010-2013 was considered the pre-expansion period and 2014-2015 the post-expansion period. We calculated 2-year mortality difference-in-difference (DID) estimates between White and non-White patients using multivariable linear regression models. Results are presented as adjusted differences (in % points) between groups in the pre- and post-expansion periods and as adjusted DID with 95%CI. Covariates included age, comorbidity, BC subtype, insurance type, transfer of care, distance to hospital, region, residence area, education, income quartile, facility type and facility volume. In addition, overall survival (OS) was evaluated in pre- and post-expansion periods via Kaplan-Meier method and Cox proportional hazards models; results are presented as 2-year OS estimates, hazard ratios (HRs), and 95% CIs. Results: Among 7,675 patients included, 4,942 were diagnosed in the pre- and 2,733 in the post-expansion period. We observed a reduction in 2-year mortality rates in both groups according to Medicaid expansion. Among Whites 2-year mortality decreased from 42.5% to 38.7% and among non-Whites from 45.4% to 36.4%, resulting in an adjusted DID of -5.2% (95%CI -9.8 to -0.6, p = 0.027). A greater reduction in 2-year mortality was observed among non-Whites in a sub-analysis of patients who resided in the poorest quartile (n = 1372), with an adjusted DID of -14.6% (95%CI -24.8 to -4.4, p = 0.005). In the multivariable Cox model, during the pre-expansion period there was an increased risk of death for non-Whites compared to Whites (HR 1.14, 95% CI 1.03 to 1.26, P = 0.04), however no differences were seen in the post-expansion period between the two groups (HR 0.93, 95% CI 0.80 to 1.07, P = 0.31). Conclusions: Medicaid expansion reduced racial disparities by decreasing the 2-year mortality of non-White patients with metastatic breast cancer and reducing the gap when compared to Whites. These results highlight the positive impact of policies aimed at improving equity and increasing access to health care.