Affordable Care Act (ACA) Medicaid expansion impact on racial disparities in time to cancer treatment
Medicaid is a US government program that provides health insurance for people with limited resources. The Affordable Care Act in 2010 significantly expanded eligibility and funding of Medicaid from 2014 with individual states opting into the expansion.
This retrospective observational study determined the effect of the expansion of Medicaid on racial disparities in time to treatment for patients with an advanced cancer. Patients aged 18-64 years with advanced cancer diagnosed between Jan 1, 2011 and Dec 31, 2018 were classified by expansion status of their state of residence and timeliness of 1st-line treatment (within 30 days of diagnosis). Of the 30,386 included patients, timely treatment occurred in 48.3% of whites vs 43.5% of blacks in non-expanded states and in 50.3% of whites vs 49.6% of blacks in expanded states for a 4.0% reduction in disparity.
Many had prior reservations about this ‘non-traditional’ plenary abstract and its relevance to an international audience. This was the standout plenary to me, and it was a case of had to be there to appreciate this big picture presentation. The discussant, Yousuf Zafar, gave eloquent yet confronting insights to the study along the theme of how national health care policy can reduce disparities in cancer care. ASCO made a bold statement with the selection of this abstract as the first plenary, and it easily makes my top 3.
Overall survival (OS) results of a phase III randomized trial of standard-of-care therapy with or without enzalutamide for metastatic hormone-sensitive prostate cancer (mHSPC): ENZAMET (ANZUP 1304), an ANZUP-led international cooperative group trial.
ENZAMET was an open-label, international, phase III, randomised trial that compared the addition of enzalutamide 160mg daily or non-steroidal antiandrogen (NSSA) therapy to testosterone suppression in men with hormone-sensitive prostate cancer. Concurrent docetaxel was later allowed (after 88 men were enrolled). The primary endpoint was overall survival (OS). In the 1124 randomised men at a median 34 months of follow-up, the addition of enzalutamide reduced the hazard of death by 33% (HR, 0.67; 95% CI, 0.52 to 0.86; P=0.002). 3-year OS was 80% (enzalutamide) v 72% (NSSA). There was no additional benefit to concurrent docetaxel. Enzalutamide caused more toxicity, especially fatigue and seizures.
ENZAMET was a highlight at ASCO as a true Aussie plenary. It was presented by ex-pat oncologist Chris Sweeney, with much of the hard work also done by oncologists Ian Davis & Martin Stockler and the trial statistician Andrew Martin, along with many other Aussie and international co-investigators and colleagues from ANZUP and the NHMRC Clinical Centre. On the science side, it has added another option to the 1st-line treatment for men with metastatic hormone-sensitive prostate cancer. Sincere congratulations to all involved. Thank you for flying the flag.
Evaluating unconscious bias: Speaker introductions at an international oncology conference
Moving on to equity in a different space, my third pick delves into the unconscious bias in speaker introductions at ASCO.
This was a retrospective observational study of 781 video presentations of 2017 and 2018 ASCO Annual Meetings. Mixed-gender and racial coders categorised speaker introductions by (i) professional form of address (Dr. full name, Dr. last name) and (ii) non-professional form of address (first name only, first & last name, last name only). Compared with male speakers, female speakers were less like likely to have a professional address (62% vs 81%, p<0.001) and were more likely to be introduced by their first name only (17% vs 3%, p<0.001). Gender differences in forms of address were present for male introducers but not female introducers.
I love how this simple, well-designed study brings unconscious bias about gender equity into the international oncology arena and adds to the momentum of embracing diversity in our workplace. In showing that small things matter, it has added much more to the larger conversation about gender equity and will result in meaningful change in speaker introduction at future conferences. This study was not a rigorously conducted randomised trial, nor a study concerning clinical practice. It did, however, ask the right question at the right time in the turning tide of gender equity, and therefore was big on impact and so makes my top 3.