Professional Documents
Culture Documents
www. AJOG.org
ONCOLOGY
rolled under the Breast and Cervical Cancer Prevention and Treatment
Act in Georgia.
STUDY DESIGN: Georgia Comprehensive Cancer Registry and Medicaid 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.
proved hospital nearby were more likely to receive surgery. Among invasive cases, later stage was associated with higher odds of receiving
radiation or chemotherapy. Black patients were less likely to have surgery than white patients regardless of preinvasive (P .01) or invasive
status (P .05).
CONCLUSION: Treatment patterns among Georgia Medicaid cases ap-
pear appropriate to stage but 18% with invasive cervical cancer received 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.
passed the Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) in
2000 to give states the option of offering
women in the NBCCEDP access to treatment through a special Medicaid coverage.22 BCCPTA was adopted quickly by all
50 states, and Georgia began enrolling
their patients into the Womens Health
Medicaid Program (WHMP) in July
2001. Although BCCPTA mandated that
women be screened by the NBCCEDP,
states had options to extend eligibility to
women screened by non-NBCCEDP providers. Georgia is 1 of 12 states that selected
this more expansive screening option. In
2005, only 25% of BCCPTA women were
screened in health departments through
Georgias NBCCEDP screening program
(known as Breast Test and More); the
majority (75%) of them were screened by
private providers.23 Women will be continuously eligible for BCCPTA as long as
they are considered under cancer treatment by their physicians, although states
differ in their redetermination process. In
2003, BCCPTA women in Georgia could
simply self-report to WHMP every 6
months indicating they were in active
treatment.23
Our earlier work found that BCCPTA
implementation in Georgia led to an in-
533.e1
Research
Oncology
www.AJOG.org
cedural Terminology (CPT) schema for
medical billing.
The county data were from Area Resource File (ARF), Commission on Cancer (CoC), and Consolidated Analysis
Center, Incorporated (CACI). The ARF,
assembled by the Health Resources and
Services Administration, provides a variety of county-level data for the 159 counties in Georgia. The CoC, established by
the American College of Surgeons, provides data on hospitals that are able to
comply with established CoC standards26 to deliver cancer care. The CACI
US Marketing Systems Group provides
data on households income level at the
county level.27
Study sample
Incident cervical cancer cases in the
GCCR between July 1, 2001, and Dec. 31,
2004, were linked to the Medicaid enrollment file using the patients encrypted
social security number for those identified with a primary site of cancer of cervix (local stage and beyond) (n 470).
We excluded those who enrolled in Medicaid more than 6 months after being diagnosed based on the assumption that
they did not require Medicaid for cancer
treatment on diagnosis (n 25). We
note that the 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 and
were not invasive cervical or breast cancer cases in the GCCR (n 1539).
Of the remaining sample (n 1984),
we excluded those who had more than 1
primary cancer site because their cancer
treatment can be affected by other cancers. To ensure that all women can be
followed for at least for 2 years, we excluded those over 63 years because their
medical claims converted to Medicare at
age 65. Those not continuously enrolled
in Medicaid in the first 2 months were
also excluded because they might not actually be eligible for Medicaid but,
rather, were given presumptive eligibility. The final sample was 1937 patients
covered by Medicaid, 1149 of whom
were diagnosed with preinvasive disease,
444 of whom were diagnosed with invasive cervical cancer and 344 of whom we
Oncology
www.AJOG.org
Research
TABLE 1
Summary of characteristics of Medicaid enrollees diagnosed with preinvasive and invasive cervical cancer
Classification, %
Variable
Preinvasive (n 1149)
Invasive (n 444)
29.1 (9.6)
42.6 (10.5)
Unstaged (n 344)
Total
34.3 (12.1)
33.1 (11.7)
.......................................................................................................................................................................................................................................................................................................................................................................
19-24
41.7
4.5
27.6
30.7
25-34
34.3
19.1
29.7
30.0
35-44
15.8
33.6
20.1
20.6
45-63
8.3
42.8
22.7
18.7
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
Race/Ethnicity
.......................................................................................................................................................................................................................................................................................................................................................................
Non-Hispanic white
66.8
54.7
62.8
63.3
Non-Hispanic black
27.0
39.4
30.2
30.4
6.2
5.9
7.0
6.2
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
Others
................................................................................................................................................................................................................................................................................................................................................................................
Stage at diagnosis
.......................................................................................................................................................................................................................................................................................................................................................................
CIN 2
64.8
38.5
35.2
20.9
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
Local
50.0
11.5
Regional
39.6
9.1
Distant
10.4
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
2.4
.......................................................................................................................................................................................................................................................................................................................................................................
Unstaged
100.0
17.8
................................................................................................................................................................................................................................................................................................................................................................................
Comorbidity index
.......................................................................................................................................................................................................................................................................................................................................................................
85.4
58.8
81.7
78.6
.......................................................................................................................................................................................................................................................................................................................................................................
11.3
22.1
10.5
13.6
3.1
16.4
7.0
6.9
Missing
0.2
2.7
0.9
0.9
Preenrolled
15.8
23.0
15.1
17.3
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
BCCPTA
98.5
55.2
94.2
87.8
Disable
0.2
23.6
2.0
5.9
Others
1.3
21.2
3.8
6.3
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
Enrollment status
.......................................................................................................................................................................................................................................................................................................................................................................
20.2 (5.1)
17.9 (7.0)
19.8 (5.6)
19.6 (5.7)
49.2
41.0
46.5
46.8
.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
Residence
.......................................................................................................................................................................................................................................................................................................................................................................
33.9
30.0
35.8
33.4
24.3
40.5
28.5
28.8
35.4
25.7
31.1
32.4
6.2
3.8
4.7
5.4
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
Completely rural
.......................................................................................................................................................................................................................................................................................................................................................................
Missing
0.2
0.0
0.0
0.1
................................................................................................................................................................................................................................................................................................................................................................................
26.3 (9.2)
23.7 (9.8)
25.4 (9.2)
25.5 (9.4)
36.1
51.1
41.0
40.4
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
0.21 (0.18)
0.26 (0.20)
0.24 (0.20)
0.22 (0.19)
................................................................................................................................................................................................................................................................................................................................................................................
BCCPTA, Breast and Cervical Cancer Patient Treatment Act; CoC, Commission on Cancer.
Chien. Cervical cancer treatment under BCCPTA. Am J Obstet Gynecol 2011.
533.e3
Research
Oncology
www.AJOG.org
FIGURE 1
FIGURE 2
533.e4
Statistical analysis
Logistic regressions were used to estimate the odd ratios (ORs) of independent variables associated with the receipt
of cervical cancer treatment. All analyses
were conducted using STATA version
9.2 (STATA Corp, College Station, TX).
R ESULTS
Basic characteristics
The patients (Table 1) with preinvasive
cervical disease (59%) exceed those with
invasive (23%) or unstaged cervical cancer
(18%). A large proportion of patients with
precancerous disease were between the
ages of 19 and 24 (41.7%), non-Hispanic
white (66.8%), with CIN 2 stage (64.8%),
and no comorbidity (85.4%). A full 98.5%
were enrolled under the BCCPTA eligibility category, whereas 15.8% enrolled before their cancer diagnosis (preenrolled)
and 49.2% were enrolled for over 24
months. The mean duration of enrollment
for this group was 20 months in 2-year follow-up period.
Compared with preinvasive cases, we
found that invasive cancer patients were
older, more likely to be non-Hispanic
black, with higher comorbidities, and
more likely to be preenrolled but less
likely to enroll under BCCPTA or be enrolled over 24 months. With respect to
county variations, they were more likely
Oncology
www.AJOG.org
to reside in a county with a higher income population and Ob/Gyn per 1000
women but with no hospital with CoC
approval, relative to their counterparts.
Descriptive analysis
Figure 1 showed the types of cervical
cancer treatment patients received
within 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 radiation, and 54% had any chemotherapy.
As further explored, the choices of
treatment among the 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 treatment for their disease
(Figure 2). For invasive cases, overall,
15% had invasive surgery, 51% had radiation and/or chemotherapy, 17% had
both, and 18% received no cancer treatment (Figure 3). While we additionally
discussed the treatment according to
stage of cancer, surgery was a major procedure for treating patients with local
stage (29%), whereas radiation and/or
chemotherapy were mainly used for
treating those with regional or distant
(69% and 78%). We also found that patients with local stage of cervical cancer
had the highest rate (24%) of no treatment or minimal treatment (only 32% of
them receiving a conization).
Multivariate analysis
Table 2 showed summary multiple regression results (only significant variables) on the receipt of any cancer
workup, precancerous procedure, and
simple hysterectomy among patients
with preinvasive disease. Patients at an
older age, with a comorbidity, and continuously enrolled over 24 months were
more likely to receive any cancer workup.
Those more likely to receive precancerous procedures were those of younger
age, non-Hispanic black, CIN 2 disease,
with no comorbidity, and residing in a
Research
FIGURE 3
24%
100%
15%
199%
7%
699%
78%
2%
%
0%
Distant
17%
30%
29%
Local
Regiional
18%
%
17%
%
50%
%
15%
%
Overall
C OMMENTS
BCCPTA is a policy approach for addressing the challenges of the uninsured
facing serious illness by providing cancer
treatment through a special Medicaid eligibility option. Our study found that
virtually all of the patients with preinva-
533.e5
Research
Oncology
www.AJOG.org
TABLE 2
Independent variables
Age at enrollment, y
OR
95% CI
..........................................................................................................................................................
19-24
0.42 0.240.71
25-34
0.41 0.240.71
35-44
0.38 0.210.68
..........................................................................................................................................................
..........................................................................................................................................................
...................................................................................................................................................................
Comorbidity index
..........................................................................................................................................................
1.81 1.202.72
3.39 1.428.09
..........................................................................................................................................................
...................................................................................................................................................................
Enrolled over 24 mo
1.54 1.201.98
..............................................................................................................................................................................................................................................
..........................................................................................................................................................
19-24
15.73 8.9127.77
25-34
4.51 2.707.55
..........................................................................................................................................................
...................................................................................................................................................................
Race/ethnicity
..........................................................................................................................................................
Non-Hispanic black
1.92 1.292.86
..........................................................................................................................................................
Others
1.92 1.013.64
...................................................................................................................................................................
0.37 0.270.51
...................................................................................................................................................................
..............................................................................................................................................................................................................................................
Simple hysterectomy
Age at enrollment, y
..........................................................................................................................................................
19-24
0.03 0.020.06
25-34
0.20 0.120.34
..........................................................................................................................................................
...................................................................................................................................................................
Non-Hispanic black
0.48 0.310.76
3.87 2.735.48
...................................................................................................................................................................
...................................................................................................................................................................
Comorbidity index
..........................................................................................................................................................
1.62 1.012.60
...................................................................................................................................................................
Covariates included age at enrollment, race/ethnicity, stage of disease, comorbidity, preenrolled, enrolled over 24 mo,
residence county variables (rural/urban, percentage households income $15K, with a CoC approval hospital, percentage
Ob/Gyn per 1000 women).
BCCPTA, Breast and Cervical Cancer Patient Treatment Act; CI, confidence interval; CoC, Commission on Cancer; OR, odds
ratio.
Chien. Cervical cancer treatment under BCCPTA. Am J Obstet Gynecol 2011.
been diagnostic and therapeutic. However, if their disease was more advanced,
then the conization was only diagnostic.
Although the observed treatment may be
appropriate based on this more specific
stage, such information was not available
to us.
Several covariates affect the patterns of
cervical cancer treatment. Younger
women were less likely to undergo surgery because of childbearing age.32 Similar to previous work,33,34 we found that
non-Hispanic black patients were less
likely to receive surgical treatment for
both preinvasive and invasive cervical
Oncology
www.AJOG.org
nearly 11% of the lowest-income patients diagnosed with invasive cervical
cancer received no treatment. To increase the rate of treatment in this vulnerable group, patient navigation intervention might have an impact. It has been
shown to successfully improve mammography screening rates for low-income minority populations in several studies.37-40
Relevant to our study population, a patient
navigation system for women with breast
cancer and a Community Health Advocates (CHA) program implemented
through Atlantas inner-city hospital led to
an increase in stage 0 breast cancer cases
from 12.4% to 25.8%; the vast majority of
participating women were African-American.41 Clearly devoting financial resources
to patient navigation for cervical cancer as
with breast cancer may improve patient
follow-up in this vulnerable group.
Although this is one of the few studies
to examine BCCPTA women, there are
several limitations. First, the data cannot
be generalized as states operate BCCPTA
programs differently. Moreover, Georgia is 1 of 12 states that selected the most
expansive coverage,35 which potentially
enrolled more uninsured women. This
greater access might result in larger variation in cervical cancer treatment patterns compared with states with more restrictive coverage.
Second, although the optimal treatment
is largely based on stage of disease, the
womans age and her childbearing plans,
and physicians and patients preferences
are part of the decision process36 and we
were not able to control for unseen variation (eg, individual preferences) that likely
affect treatment decisions.
We were unable to track patients cervical cancer treatment if their treatment was
out of Medicaid claims, out of the study
period, or out of cancer treatment as we
defined it. In addition, we would not know
the treatment patterns of those who enrolled in Medicaid more than 6 months after diagnosis. Those patients might have
enrolled in Medicaid under BCCPTA but
actually received treatment before enrolling. Finally, we found that 4% of preinvasive cervical cases received chemotherapy
that might not be clinically appropriate;
these women may have other types of cancer that we were unable to detect.
Research
TABLE 3
Independent variables
Stage of disease
OR
95% CI
...................................................................................................................................................
Regional
3.03
1.545.98
Distant
6.55
1.6526.05
...................................................................................................................................................
............................................................................................................................................................
Comorbidity index
...................................................................................................................................................
3.27
1.387.75
...................................................................................................................................................
5.68
1.7618.28
Preenrolled
2.85
1.316.23
BCCPTA
4.09
1.878.94
Enrolled over 24 mo
2.40
1.214.76
Non-Hispanic black
0.61
0.371.00
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
..............................................................................................................................................................................................................................................
............................................................................................................................................................
Stage of disease
...................................................................................................................................................
Regional
0.32
0.200.52
Distant
0.10
0.030.32
Preenrolled
2.08
1.133.85
Disabled
0.29
0.140.64
...................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
..............................................................................................................................................................................................................................................
Any radiation
Stage of disease
...................................................................................................................................................
Regional
10.25
5.8218.06
Distant
6.36
2.7014.95
...................................................................................................................................................
............................................................................................................................................................
Comorbidity index
...................................................................................................................................................
2.39
1.154.99
2.01
1.193.39
............................................................................................................................................................
Enrolled over 24 mo
..............................................................................................................................................................................................................................................
Any chemotherapy
Stage of disease
...................................................................................................................................................
Regional
5.57
3.439.03
Distant
3.98
1.908.32
...................................................................................................................................................
............................................................................................................................................................
Comorbidity index
...................................................................................................................................................
2.22
1.184.20
..............................................................................................................................................................................................................................................
Covariates included age at enrollment, race/ethnicity, stage of disease, comorbidity, preenrolled, Medicaid eligibility groups,
enrolled over 24 mo, residence county variables (rural/urban, percentage households income $15K, with a CoC approval
hospital, percentage Ob/Gyn per 1000 women).
BCCPTA, Breast and Cervical Cancer Patient Treatment Act; CI, confidence interval; CoC, Commission on Cancer; OR, odds
ratio.
Chien. Cervical cancer treatment under BCCPTA. Am J Obstet Gynecol 2011.
REFERENCES
1. What are the key statistics about cervical
cancer? 2009. Available at: http://www.cancer.
533.e7
Research
Oncology
org/docroot/CRI/content/CRI_2_4_1X_What_
are_the_key_statistics_for_cervical_cancer_8.
asp?rnavcri. Accessed July 21, 2009.
2. Schoell WMJ, Janicek MF, Mirhashemi R.
Epidemiology and biology of cervical cancer.
Sem Surg Oncol 1999;16:203-11.
3. Devesa SS, Silverman DT, Young JLJ, et al.
Cancer incidence and mortality trends among
whites in the United States, 1947-84. J Natl
Cancer Inst 1987;79:701-70.
4. Casper MJ, Clarke AE. Making the Pap
smear into the Right Tool for the job, cervical
cancer screening in the USA, circa 1940-95.
Soc Stud Sci 1998;28:255-90.
5. Bradley CJ, Given CW, Roberts C. Health
care disparities and cervical cancer. Am J Public Health 2004;94:2098-103.
6. Akers AY, Newmann SJ, Smith JS. Factors
underlying disparities in cervical cancer incidence, screening, and treatment in the United
States. Curr Prob Cancer 2007;31:157-81.
7. Breen N, Wagener DK, Brown ML, Davis
WW, Ballard-Barbash R. Progress in cancer
screening over a decade: results of cancer
screening from the 1987, 1992, and 1998 National Health Interview Surveys. J Natl Cancer
Inst 2001;93:1704-13.
8. Sung JFC, Alema-Mensah E, Blumenthal DS.
Inner-city African American women who failed to
receive cancer screening following a culturallyappropriate intervention: the role of health insurance. Cancer Detect Prevent 2002;26:28-32.
9. Hewitt M, Devesa SS, Breen N. Cervical cancer screening among U.S. women: analyses of
the 2000 National Health Interview Survey. Prevent Med 2004;39:270-8.
10. Roetzheim RG, Pal N, Tennant C, et al. Effects of health insurance and race on early
detection of cancer. J Natl Cancer Inst 1999;
91:1409-15.
11. Rodriguez MA, Ward LM, Perez-Stable EJ.
Breast and cervical cancer screening: impact of
health insurance status, ethnicity, and nativity of
Latinas. Ann Fam Med 2005;3:235-41.
12. Harlan LC, Greene AL, Clegg LX, Mooney M,
Stevens JL, Brown ML. Insurance Status and the
use of guideline therapy in the treatment of selected cancers. J Clin Oncol 2005;23:9079-88.
13. Thorpe KE, Howard D. Health insurance
and spending among cancer patients. Health
533.e8
www.AJOG.org
Aff (Millwood). 2003 Jan-Jun;Suppl Web
Exclusives:W3-189-98.
14. Miller B, Ries L, Hankey B, Kosary C. SEER
Cancer Statistics Review: 1973-1990. Betheseda: National Cancer Institute; 1993.
15. Weiss L, Kau T, Sparks B, Swanson G.
Trends in cervical cancer incidence among
young black and white women in metropolitan
Detroit. Cancer 1994;73:1849-54.
16. Mangan SA, Legano LA, Rosen CM, et al.
Increased prevalence of abnormal Papanicolaou smears in urban adolescents. Arch Pediatr
Adolesc Med 1997;151:481-4.
17. Center for Disease Control and Prevention.
National breast and cervical cancer early detection program. Atlanta, GA: CDC; 2009.
18. About the program. 2009. Available at:
http://www.cdc.gov/cancer/NBCCEDP/about.
htm. Accessed July 21, 2009,
19. Adams EK, Florence CS, Thorpe KE, Becker
ER, Joski PJ. Preventive care: female cancer
screening, 1996-2000. Am J Prevent Med
2003;25:301-7.
20. Chattopadhyay SK, Hall HI, Wolf RB, Custer
WS. Sources of health insurance in the U.S.:
analysis of state-level data and implications for
public health programs. J Public Health Manage Pract 1999;5:35-46.
21. Paula ML, Lisa CR, Debra JM, Lisa RS,
Donna BK, Lowell ES. Strategies for follow-up
and treatment services in state breast and cervical cancer screening programs. Womens
Health Issues 1999;9:42-9.
22. Medicaid Eligibility Overview. CMS, 2009. Available at: http://www.cms.hhs.gov/Medicaid
Eligibility/01_Overview.asp. Accessed Feb. 20,
2009.
23. Adams EK, Blake SC, Raskind-Hood C, et
al. The Breast and Cervical Cancer Prevention
and Treatment Act (BCCPTA) in Georgia:
women covered and Medicaid costs in 2003. J
Georgia Public Health Assn 2007;1:1-10.
24. Adams EK, Chien L-N, Florence CS, Raskind-Hood C. The Breast and Cervical Cancer
Prevention and Treatment Act in Georgia.
Cancer 2009;115:1300-9.
25. Chien L-N, Adams EK. The effect of the
Breast and Cervical Cancer Prevention and
Treatment Act on Medicaid disenrollment.
Womens Health Issues 2010;20:266-71.