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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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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