Many studies have been performed to identify disparities in breast cancer care among diverse populations [11–16,18,32,33,34]. Several factors contribute to these disparities including age, race, ethnicity, education. health literacy, employment, household income, insurance status, socioeconomic status, and social/family support. Few studies, however, have provided or attempted to provide solutions on how to improve these disparities. The current study found that after implementation of the cost limiting approach, patients were more likely to undergo breast conservation, have fewer operations, and more likely to undergo adjuvant treatments. These changes resulted in a lower risk for recurrence and death. Our study provides one approach on how to circumvent common breast cancer care barriers to improve outcomes in uninsured and low-income populations.
Our study population is like many groups at risk for inadequate breast cancer care. Although the population was a common age seen in breast cancer studies, the majority were racial/ethnic minorities, almost half non-English speaking, and only 43% married/domestic partner. In addition, the population was undereducated and almost 80% had inadequate health literacy. Only 30% were employed and the mean monthly income was $1063. This is about 60% below the Federal poverty guideline of $31,200 per year [35]. As shown in Table 2, cost of standard of care breast cancer treatment can be exorbitant for uninsured patients. Even for treatment where chemotherapy is not indicated, the cost would be three times the annual income of the population studied. With chemotherapy, the costs are increased by over $100,000. These costs do not include the costs for office visit copays and each additional operation for positive margins. An alarming 56% of the population was uninsured/self-pay and 31% AHCCCS (Medicaid). The rate of uninsured patients in the current study increased in the ACS period despite changes by the Affordable Care Act to increase access to health care. Lack of insurance or being insured by Medicaid both have been associated with poor breast cancer outcomes [11,13]. With the out of pocket costs shown in Table 2, it was not surprising that compliance with recommended adjuvant therapy was lower prior to the implementation of the cost saving approach for patients. With the cost saving changes, the patient costs decreased by approximately $23,000 when chemotherapy was not indicated and by $130,000 when chemotherapy was recommended.
Delays in breast cancer treatment start with a delay in diagnosis [36]. One study found the time interval from presentation to diagnosis of 23 days and from presentation to first treatment of 65 days. These intervals were longer Hispanic and underinsured patients [37]. The cost saving approach described lessens the likelihood of a patient having a time interval between awareness of an abnormality on breast imaging or physical examination and the biopsy to obtain a diagnosis (Table 2). The biopsy on the same day as initial consultation also lowers the costs for the patient because it does not require a separate visit or visit to another location. Racial/ethnic minority groups have been shown to be diagnosed at younger ages and more commonly with triple negative breast cancer than non-Hispanic White women [22,38,39]. Many of these patients are appropriate candidates for genetic counseling and testing. Under most circumstances these services would require a separate appointment. As shown in Table 2, however, ACS patients eliminate three appointments and save over 2 months from presentation to operation. Many clinicians routinely recommend and order breast MRI on every breast cancer patient. This practice is performed despite studies demonstrating no benefit to lower the need for re-excision lumpectomy, fewer local recurrences, or improved overall survival [40,41,42]. As part of the Choose Wisely Campaign, the American Society of Breast Surgeons recommends against the routine use of MRI in newly diagnosed breast cancer patients [43]. Preoperative breast MRI was not performed on patients in the current study and therefore saved patients out of pocket costs. With an average household come one-third of the Federal poverty threshold, any additional costs are critical.
Despite the poor use of screening mammography, presentation with palpable masses and at later stages, once the cost saving approach was implemented, the rate of breast conservation was improved from 47–75%, p < 0.001. This improvement in the rate of breast conservation was likely due to the increased availability of radiation therapy. Without a plan to obtain discounted radiation therapy and funding to support the costs, many patients in the BCS group likely opted for, or were told to have, mastectomy, even if they were appropriate candidates for breast conservation. The rate of breast conservation that was achieved is higher than that reported in most other studies involving underinsured, low-income safety net populations [13,44]. Preoperative breast magnetic resonance imaging was not utilized and the rate of positive margins decreased after the cost saving approach was implemented. The rate of positive margins (15%) was low relative to other reported studies (35%) and even comparable to other studies which utilized intraoperative margin assessment [27,45,46]. The satisfactory rate of breast conservation and positive margins, despite presentation with larger palpable tumors and at later stages, may raise concern that breast conservation was overutilized, possibly putting patients at increased risk for local recurrence and death. The results in Table 4, however, show a low rate of ipsilateral breast tumor recurrence after breast conservation (2.2%) and death from breast cancer at median follow up of 8.1 years [47]. The low rate of positive margins may be reflective of the increased use of preoperative chemotherapy (47% vs 17%, p < 0.001) after the cost saving approach was implemented. Preoperative chemotherapy results in some percentage of pathologic complete response. In this situation, negative margins are ensured as there is no residual cancer [48,49]. In addition, several studies have demonstrated that intraoperative ultrasound can lower the risk for positive margins, and this technique was used throughout the time after the cost saving approach was implemented [50,51]. Fewer positive margins in an uninsured population are critically important to minimize the number of operations and therefore out of pocket costs. For patients who required or chose mastectomy, there was an increase in the number of patients who were able to undergo reconstruction during the ACS (38% vs 6%, p < 0.001). It is not clear how this change occurred as there was no provision to lessen the cost of reconstruction to the uninsured patients. Two possibilities are that, first reconstruction was offered as an option more often after the cost saving approach was implemented, and second patients may have been more likely to take advantage of the down payment only requirement prior to operations.
Overall survival improved to 90% with a majority of patients presenting at stage II or later. Studies have demonstrated that patients insured with Medicaid have outcomes similar to uninsured patients rather than privately insured/commercial insurance patients [52,53,54]. This improvement in survival was likely due to the increased use of all types of adjuvant therapy during the ACS period. Use of recommended chemotherapy increased from 70–91%, p < 0.001. As discussed in the Methods section, for luminal breast cancer, the multigene assay was used to help determine the indication for chemotherapy [29]. Chemotherapeutic medications were obtained through the assistance of Cardinal Health [30]. The level of assistance and process likely varies based on the individual medical centers. Determination of qualification for financial assistance for genetic testing, multigene assay testing, and chemotherapy, however, did have similar requirements. All required patient identification, household size, and documentation of income. The documentation of income was typically with the W-2. If no W-2 was available, then a letter from the clinician and patient could be submitted to explain why no documentation of income was available and the best estimate of the household income.
Radiation therapy use increased from 70–90% during the ACS (p < 0.001). The acceptable rate of breast conservation combined with 90% compliance with radiation therapy was an accomplishment compared to a previous study finding 40–65% compliance with radiation therapy [53,55]. Obtaining radiation therapy is the most problematic step in treatment of uninsured patients. Commercial insurance, Medicare, and Medicaid/AHCCCS all cover radiation therapy. Uninsured/self-pay patients must pay out of pocket. Although cost of radiation therapy varies from state to state, a study based on Medicare reimbursements estimated the cost between $7300 to $10,300 with another study estimating $14,910 [56,57]. This cost approaches the average annual income of the population studied. The ability to negotiate a discounted rate for the radiation therapy with a generous radiation oncology group greatly facilitated the treatment. The fund raising and obtainment of treatment grants by the Health Foundation of the hospital also assisted in payment for the treatment. Other studies have reported respectable rates of radiation therapy in safety net populations but had a comparatively very low (9%, 0%, 17% (combined with Medicaid)) percentage of uninsured patients and no explanation as to how the treatment was funded [58,59,60]. Other than the method used in the current study, other potential options include obtaining treatment from government funded facilities such as Veteran’s Administration hospitals or teaching facilities. These type of radiation facilities may be more capable of withstanding lower reimbursement for radiation therapy.
Initiation of endocrine therapy was improved by a similar magnitude with the implementation of the cost saving approach. The same indications for endocrine therapy were used in both time periods. Cost of endocrine therapy is small relative to all other facets of breast cancer treatment. One possible explanation for the improvement is that once patients completed other parts of adjuvant therapy, they realized the importance of multidisciplinary treatment and followed through with the endocrine therapy [61].
One limitation is that prolonged compliance with endocrine therapy was not measured. One previous study found higher rates of discontinuation in patients with low income and either Medicaid or self-pay compared to those with private insurance [62]. This study has other limitations as well. Retrospective studies are subject to inherent limitations and biases. Data from prospective studies involving minority uninsured patients, however, are very difficult to obtain even in a disease as common as breast cancer. This study was from one institution, but with a population subject to many disparities. Although outcomes such as local recurrence and survival were reported in this study, the authors feel that the more important aspect of this study is the methodology employed to care for this population.