Ling Chen

Uterine cancer diagnosis at age 65: onset of Medicare eligibility and impact of Medicaid expansion

Uterine cancer, for which diagnosis is based on evaluation of symptoms, most commonly postmenopausal bleeding, is one of the few cancers in the United States with rising incidence and mortality. Inability to access diagnostic services due to lack of insurance coverage may lead to delayed diagnosis and inferior outcomes. The aim of the study was to examine whether the onset of Medicare eligibility at age 65 was associated with a spike in the incidence of uterine cancer and whether this association was attenuated by Medicaid expansion through the Affordable Care Act. This ecological study used cancer registry data from the Surveillance, Epidemiology, and End Results program to estimate the incidence rate of uterine cancer among women aged 55 to 74 from 2000 to 2021 in the United States. Second order polynomial modeling was used to fit the association between age (in single years) and incidence rate at the population level while excluding age 65 to identify the expected incidence rate at age 65 in the absence of a spike. The expected uterine cancer incidence rate at age 65 was generated from the model and compared to the observed rate at age 65 in the overall sample. Similar analyses were also conducted further stratified by stage, race and ethnicity, pre-Affordable Care Act (2004-2013) versus post-Affordable Care Act (2014-2021) period and states' Medicaid expansion status. In the overall sample, the observed uterine cancer incidence rate at age 65 was 108.2 cases per 100,000 woman-years (95% confidence interval, 106.4 to 110.1), which exceeded the expected rate projected from the polynomial model (102.5; 95% confidence interval, 101.4-103.5). A similar pattern was observed in analysis stratified by stage at diagnosis and by race and ethnicity. The spike in incidence at age 65 diminished in Medicaid expansion states in the post-Affordable Care Act period but persisted in nonexpansion states. Onset of Medicare eligibility at age 65 was associated with a spike in uterine cancer diagnoses, which appeared to be mitigated by Medicaid expansion. These findings underscore the importance of insurance coverage in facilitating timely uterine cancer diagnoses.

Trends in uterine cancer incidence and mortality: insights from a natural history model

Abstract Background Uterine cancer incidence and mortality are increasing, with concomitant disparities in outcomes between racial groups. Natural history modeling can evaluate risk factors, predict future trends, and simulate approaches to reducing mortality and disparities. Methods We designed a natural history model of uterine cancer using a multistage clonal expansion design. The model is informed by National Health and Nutrition Examination Survey, National Health Examination Survey, age, time period, birth cohort, and birth certificate data on reproductive histories and body mass index (BMI). We fit and calibrated the model to Surveillance, Epidemiology, and End Results data by race and ethnicity as well as histologic subgroup. We projected future incidence and estimated the degree of contribution of BMI, reproductive history, and competing hysterectomy to excess uterine cancer incidence. Results The model accurately replicated Surveillance, Epidemiology, and End Results incidence for endometrioid, nonendometrioid, and sarcoma subgroups for non-Hispanic Black and non-Hispanic White patients. For endometrioid, nonendometrioid, and sarcomas, BMI-attributable risks are greater for non-Hispanic White than for non-Hispanic Black patients; reproductive history–attributable risks are greater for non-Hispanic Black patients. Between 2018 and 2050, endometrioid incidence is projected to rise by 64.9% in non-Hispanic Black individuals and17.5% in non-Hispanic White individuals; the projected rise for the nonendometrioid subgroup is 41.4% in non-Hispanic Black individuals and 22.5% in non-Hispanic White individuals; the sarcoma incidence projected increase is 36% in non-Hispanic Black individuals and 29.2% in non-Hispanic White individuals. Conclusions Uterine cancer risk is substantially explained by reproductive history and BMI, with differences observed between non-Hispanic Black and non-Hispanic White individuals and future projections indicating perpetuation of disparities. Lower rates of hysterectomy and rising obesity rates will likely contribute to continued increases in uterine cancer incidence.

Use and outcomes of hormonal therapy for advanced-stage, low-grade serous ovarian cancer.

To examine trends in the use of hormonal therapy for advanced-stage, low-grade serous ovarian carcinoma and to compare survival outcomes of patients who received traditional chemotherapy, hormonal therapy alone, or the combination of both. Women with stage II to IV low-grade serous ovarian cancer diagnosed between 2011 and 2020 were identified from the National Cancer Data Base. Patients undergoing primary surgery followed by adjuvant chemotherapy, hormonal therapy, or both were included. A multinomial logistic regression model was used to examine factors associated with treatment. Propensity score-weighted Cox proportional hazards models (via inverse probability of treatment weighting) were applied to compare overall survival across the treatment groups. Among 1532 women, 68.0% received chemotherapy alone, 12.3% received hormonal therapy alone, and 19.8% received combination therapy. Use of hormonal monotherapy increased from 0.8% in 2011 to 27.4% in 2020, and use of combination therapy increased from 0.8% to 32.6% (p 70 years) (p = .001) and those with Medicare insurance (p < .001), while combination therapy was more common in women with stage III to IV disease (p = .001). After applying propensity score weighing, 5-year survival was 76.6% (95% CI 73.2% to 79.7%) for chemotherapy alone, 85.5% (95% CI 66.1% to 94.3%) for hormonal therapy alone, and 75.8% (95% CI 59.7% to 86.2%) for combination therapy. Compared to chemotherapy alone, the HR for all-cause mortality was 0.74 (95% CI 0.46 to 1.19) for hormonal therapy alone and 0.88 (95% CI 0.63 to 1.24) for combination therapy. In advanced-stage low-grade serous ovarian cancer, the use of hormonal therapy increased substantially over time. Comparable survival outcomes across modalities suggest hormonal therapy may be a viable treatment option, particularly for patients who will not tolerate the side effects of cytotoxic chemotherapy.

Projected Trends in the Incidence and Mortality of Uterine Cancer in the United States

Abstract Background: To develop a natural history model for uterine cancer calibrated to population-based incidence and mortality data to project future trends in the disease through 2050. Methods: We developed a state-transition microsimulation model of uterine cancer. The model begins at 18 years of age and simulates Black and White patients, includes transition states for precursor lesions, and separately models endometrioid and nonendometrioid tumors. The model was calibrated to population-based incidence and mortality data using parameter extrapolation. Results: The model closely fit population-based incidence and mortality data of uterine cancer. From 2020 to 2050, the incidence of uterine cancer is projected to increase in White women to 74.2 cases per 100,000 (compared with 57.7 cases per 100,000 in 2018) and increase to 86.9 per 100,000 (compared with 56.8 cases per 100,000 in 2018) in Black women. Among White women, incidence-based mortality will increase from 6.1 per 100,000 in 2018 to 11.2 per 100,000 in 2050, whereas incidence-based mortality in Black women will increase from 14.1 per 100,000 to 27.9 per 100,000. Endometrioid tumors are expected to increase considerably in both White and Black women; White women will experience only a slight increase in nonendometrioid tumors, whereas the incidence of these tumors will increase substantially in Black women. Conclusions: The incidence and mortality of uterine cancer are projected to increase substantially over the next three decades. Black women will experience a disproportionate increase in the disease. Impact: Projecting the incidence and mortality of uterine cancer can facilitate future cancer control efforts.

Association of sentinel lymph node biopsy and isolated tumor cells in cervical cancer.

This retrospective cohort study examined 4991 patients with the American Joint Commission on Cancer T1-2 classification who underwent primary anti-cancer surgery, including lymph node evaluation (sentinel lymph node biopsy n = 976, and lymphadenectomy n = 4015), identified in the National Cancer Database from 2018 to 2022. In propensity score inverse probability of treatment weighting, the sentinel lymph node biopsy group had a 2-fold higher rate of low-volume metastasis (isolated tumor cells or micro-metastasis) than the lymphadenectomy group (2.7% vs 1.3%, OR 2.03, 95% CI 1.26 to 3.27). When the low-volume metastasis was further stratified, sentinel lymph node biopsy was associated with increased odds of isolated tumor cells (OR 2.33, 95% CI 1.30 to 4.17) compared with micro-metastasis (OR 1.58, 95% CI 0.70 to 3.57). This association was consistent in the Surveillance, Epidemiology, and End Results Program data from 2018 to 2022 (n = 2973), and sentinel lymph node biopsy was associated with increased odds of isolated tumor cells (OR 3.31, 95% CI 1.65 to 6.64) compared with micro-metastasis (OR 1.12, 95% CI 0.58 to 2.16) compared with lymphadenectomy. In conclusion, these data suggest that sentinel lymph node mapping and biopsy with ultra-staging can identify more isolated tumor cells in cervical cancer.