articulo tratamiento preventivo en cancer de mama
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7/29/2019 Articulo Tratamiento Preventivo en Cancer de Mama
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Treating cervical cancer: Breast and Cervical CancerPrevention and Treatment Act patientsLi-Nien Chien, PhD; E. Kathleen Adams, PhD; Lisa C. Flowers, MD
OBJECTIVE: To investigate cervical cancer treatment of patients en-
rolled under the Breast and Cervical Cancer Prevention and Treatment
Act in Georgia.
STUDY DESIGN: Georgia Comprehensive Cancer Registry and Medic-
aid 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.
RESULTS: Preinvasive disease cases with cervical intraepithelial neo-
plasia 3, in situ, a comorbidity or without a Commission on Cancer ap-
proved hospital nearbywere more likelyto receive surgery. Among invasive
cases, later stage was associated with higher oddsof receiving radiation or
chemotherapy. Black patients were less likely to have surgery than white
patients regardless of preinvasive (P .01) or invasivestatus (P .05).
CONCLUSION: Treatment patterns among Georgia Medicaid cases ap-
pear appropriate to stage but 18% with invasive cervical cancer re-
ceived 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.
BACKGROUND AND OBJECTIVEThe 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 treatmentthrough Medicaid. Although BCCPTA
mandated that women be screened by
the NBCCEDP, states could extend eli-
gibility to women screened by non-
NBCCEDP providers. Women are con-tinuously 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 enroll-
ment of 2-3 more women with these
cancers in a given month and shortened
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 recertification pro-
cess 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 bothcancers after BCCPTA.
The goal of BCCPTA is to provide
Medicaid coverage to assure high-qual-
ity treatment. It is important to under-
stand the cancer treatment pattern of pa-
tients diagnosed with preinvasive disease
and invasive cervical cancer under
BCCPTA.
MATERIALS AND METHODS
The major datasets used were the Geor-gia Cancer Comprehensive Registry
(GCCR), Medicaid enrollment, and
claims files. County data were from the
Area Resource File, Commission on
Cancer, and Consolidated Analysis Cen-
ter, Incorporated.
Incident cervical cancer cases in the
GCCR from July 1, 2001, through Dec.
31,2004,were linkedto the Medicaid en-
rollment file using patients encrypted
Social Security numbers for those iden-
tified with a primary site of cancer of thecervix (local stage and beyond). GCCR
did not include preinvasive (CIN 2 and
3, in situ) cervical cases; therefore, we
identified 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.
RESULTS
The Figure shows the types of cervicalcancer treatment that patients receivedwithin 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 radi-
ation, 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 treat-
ment for their disease. Forinvasive cases,
overall, 15% had invasive surgery, 51%
had radiation and/or chemotherapy,
17% had both, and 18% received no can-
cer treatment.
Among invasive cases, non-Hispanic
black patients were significantly less likely
to have invasive surgery after control forthe other covariates (P .05). Later stage
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-05-004-01-
CPHPS from the American Cancer Society.
0002-9378/free
2011 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2011.01.033
www.AJOG.org Oncology Research
JUNE 2011 American Journal of Obstetrics &Gynecology 533
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7/29/2019 Articulo Tratamiento Preventivo en Cancer de Mama
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was associated with higher odds of radia-
tion or chemotherapy, but not surgery.
BCCPTA women were no different in
terms of receiving invasive surgery, radia-
tion, or chemotherapy than other eligibil-
ity groups, whereas disabled patients wereless likely to undergo surgery.
COMMENTBCCPTA is a policy approach for ad-
dressing the challenges of the uninsured
facing serious illness by providing cancer
treatment through a special Medicaid el-
igibility option. Further analysis indi-
cated 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 fac-
tors affecting treatment, such as pa-
tient refusal because of individual be-liefs or preferences.
Lack of insurance coverage is tradi-
tionally seen as the main reason for pa-
tients not to receive timely and appro-
priate 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-
tient navigation intervention might be
helpful as it has been shown to improve
mammography screening rates for low-
income minority populations in several
studies. Devoting financial resources to
patient navigation for cervical cancer, as
with breast cancer, may improve patientfollow-up in this vulnerable population.
CLINICAL IMPLICATIONS
Expanding Medicaid for uninsured
low-income patients is a viable policy
for increasing access to care for cervi-
cal cancer patients.
The receipt of clinically appropriate
care while enrolled in Medicaid can
prevent new cases as well as improve
the prognosis and health outcomesfor those already diagnosed with cer-
vical cancer.
Evidence that preinvasive cervical pa-
tients living in a county with a Com-
mission on Cancer approved hospital
were likely to receive nonsurgical
treatment and less likely to have a hys-
terectomy may indicate that the pres-
ence of specialists and oncologists as-
sociated with this type of hospital
provides more alternative treatment
options. The effect of disenrollment on the re-
ceipt of any treatment indicates that
policy makers and providers should
work to retain women in Medicaid
until they have completed their treat-
ment 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
FIGURE
Cervical treatment of patients with preinvasiveand invasive cervical cancer under Medicaid
Chien. Cervicalcancer treatmentunder BCCPTA.AmJObstet Gynecol 2011.
Research Oncology www.AJOG.org
534 American Journal of Obstetrics &Gynecology JUNE 2011
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