Testis cancer patients fare poorly under ACA

Since passage of the Affordable Care Act (ACA) in 2010, the number of testicular cancer patients with insurance has dwindled, while rates of advanced testis cancer have climbed, according to a new study presented at the Genitourinary Cancers Symposium in Orlando, FL.

The ACA, intended to increase insurance coverage and health care access, hasn’t had those effects on testicular cancer, which is diagnosed at an average age of 33 years and is the most common cancer in men ages 15 to 44 years, according to the study.

The not-yet-published research offers two important take-home messages for urologists. One is the burden of testicular cancer, in terms of patients with stage 2 and 3 testicular cancer, which often requires multimodal treatment, hasn’t decreased. And the ACA did not necessarily improve disease detection of testicular cancer among young men in the U.S., according to senior author Simon P. Kim, MD, MPH, of University Hospitals Case Medical Center and the Urology Institute at Case Western Reserve University School of Medicine, Cleveland.

Dr. Kim told Urology Times that he was surprised by the results.

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“Other studies have shown that the Affordable Care Act improved access to health insurance for young patients, and, once they get access, early detection for locally advanced cancers, such as cervical cancer,” Dr. Kim said.

The authors studied insurance status changes and post-orchiectomy definitive therapy timeliness among men diagnosed with testicular cancer from 2007 to 2013. They identified patients from the National Cancer Database who were 18 to 50 years of age and had undergone radical orchiectomy. The men had stages 1 through 3 testicular cancer. Their insurance types at the time of diagnosis, as well as the times to secondary therapy-systemic chemotherapy, radiation therapy, or retroperitoneal lymph node dissection-were recorded.

The authors divided patients in groups of 2007 to 2009, or pre ACA, and 2011 to 2013, or post ACA.

Of the 17,945 men in the study, 53.5% had pure seminoma and 46.5% had nonseminomatous germ cell tumors. The authors found that while 74.1% of the men were privately insured pre ACA, 71.2% were so post ACA. The percentage of men without any health insurance increased slightly from 12.7% before ACA to 13.4% after.

Next: What the authors found

Nearly 32% of patients presented with clinical stage 2 or 3 testicular cancer after the ACA’s passage, which was an increase from the nearly 29% that presented with advanced disease before the act’s passage.

And when they looked at health insurance types and their impact, the authors found that privately insured patients received more timely secondary radiation therapy for the cancer, at a mean 49.9 days, than men without insurance, who waited a mean 60.9 days. Chemotherapy treatment also lagged in the non-insured group at 45.7 days for these men versus 41.5 days for men with private insurance. There was no difference in the time to retroperitoneal lymph node dissection between pre- and post-ACA groups.

There could be a few reasons for the differences in findings in this study compared to studies of the ACA’s impacts on other cancer types, according to Dr. Kim.

“Some of it is due to the fact that the uninsured rate didn’t change. And the use of health care services varies by gender: Men are less likely to see doctors and are probably less likely to engage in getting health insurance,” he said.

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It could be that the younger, healthier patient population is not getting adequate primary care to assess for the cancer, according to the study.

There also is the issue of screening. The U.S. Preventive Services Task Force has given a “D” grade to screening for testicular cancer, which is basically a scrotal exam, according to Dr. Kim.

“I think it’s important that as we think about changing health care policy in the U.S., we focus on trying to enroll more uninsured patients into insurance programs, but also to equally focus on delivering high-quality care,” he said. “Screening for patients who are young and at risk for testicular cancer… is a really critical part of doing that.”

The next step, Dr. Kim said, is to design policies aimed at improving health care, regardless of a patient’s insurance status. With testicular cancer, the focus should be to ensure that patients diagnosed with this highly curable malignancy get timely, optimal care to reduce the burden of treatment-in particular, chemotherapy and radiation. The focus should also be to improve detection so that tumors, when they’re found, are smaller and less metastatic, he said.

One of Dr. Kim’s co-authors has received research funding from Genomic Health.

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