1. Fuerst, Mark L.

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Higher public welfare expenditures can improve overall survival (OS) for Black patients and narrow racial disparities in cancer outcomes, according to a large retrospective review. States that increased investments in social services spending by 10 percent, including Medicaid and other social services for socioeconomically disadvantaged individuals, showed improved 5-year OS for non-Hispanic Black adults with cancer compared to states that did not increase spending. Racial disparities between non-Hispanic Black and White patients in cancer outcomes decreased overall for multiple cancer sites, according to research presented at the 2022 American Society of Clinical Oncology (ASCO) Annual Meeting (Abstract 6509).

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"This study underscores the critical role that state social welfare spending, including Medicaid expansion, plays in reducing cancer outcome disparities. State-funded programs can reduce barriers to accessing cancer care and impact survival," said Julie R. Gralow, MD, FACP, FASCO, Chief Medical Officer & Executive Vice President of ASCO and Professor of Breast Cancer at the University of Washington. "This important data clearly supports investments in public welfare spending at the state level."


About the Study

The researchers, led by Justin Michael Barnes, MD, MS, a radiation oncologist at Washington University School of Medicine, examined records from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) cancer database in 13 states of adults ages 18 and older newly diagnosed with cancer from 2007 to 2016. State annual spending data was obtained from the U.S. Census Bureau.


The investigators evaluated the association of 5-year OS and public welfare spending by race and ethnicity, as well as by cancer site. The analyses accounted for age, sex, metropolitan residence, state, county-level income and education, insurance status, cancer site, stage at diagnosis, and year of diagnosis. Researchers used cluster-robust regression to account for within-state correlations.


Barnes noted that Black patients with cancer have worse 5-year OS as compared with White patients (63% vs. 68% as of 2019). Racial disparities may be related to reduced access to care and various social determinants of health and structural racism, such as income, education, and place of residence. "Our study provides some answers to some of these vexing issues," said Barnes.


Key Findings

Based on data from 2.9 million adults with cancer, increasing social services spending was associated with increased 5-year OS among non-Hispanic Black patients, resulting in a decrease in racial disparities in survival between non-Hispanic Black and White patients for many types of cancers. Five-year OS was 10.8 percent lower in non-Hispanic Black compared to non-Hispanic White patients for all cancers combined.


There was a 4.55 percent narrowing of the 5-year OS disparity in non-Hispanic Black patients compared to non-Hispanic White patients per 10 percent increase in spending. Specifically, increased public welfare spending was associated with a narrowed Black compared to non-Hispanic White 5-year OS disparity for patients with cancers of the breast (6.15% survival increase for Black patients led to a 39% closing of the disparity); cervix (11.9% survival increase led to a 46% closing of the disparity); colorectum (4.42% survival increase led to a 48% closing of the disparity); head and neck (9.41% survival increase led to a 38% closing of the disparity); liver (7.02% survival increase led to a 49% closing of the disparity); ovary (8.95% survival increase led to a 41% closing of the disparity); bladder (8.18% survival increase led to a 44% closing of the disparity); and uterus (14.1% survival increase led to a 40% closing of the disparity).


Results were similar after accounting for state Medicaid eligibility limits and excluding data related to Medicaid expansions.


"Greater state public welfare spending was associated with higher 5-year OS among Black patients and decreased Black-White disparities," Barnes concluded. "Future work is needed to determine the specific, most influential public welfare expenditures. This would enable more rigorous evaluation of state-level policies and associations with outcomes, and lead to subjects of future advocacy efforts."


Next Steps

The researchers hope to more closely examine the various components of public welfare expenditures to better determine which components play the most important roles. Also, they are considering additional studies to compare changes in outcomes with changes in welfare policies over time, thereby helping confirm the associations observed in this study.


"The data are thought-provoking. I see this as a proof-of-concept project. Hopefully, ultimately, policy changes will improve outcomes for all our patients and help close the gap in race-based disparities," Barnes noted.


Mark L. Fuerst is a contributing writer.