Advocate Analysis: The quality of breast cancer care provided by the California BCCTP to uninsured women

July 13, 2010

This is the first study to assess quality of breast cancer care received though the Breast and Cervical Cancer Treatment Program (BCCTP) in the nearly ten years since the expansion of Medicaid coverage of treatment for women diagnosed with breast cancer through a federal screening program. The study found that women treated for breast cancer in the California BCCTP received care comparable to or better than that received by a previously studied cohort of largely insured women in a hospital-based cancer registry, using a set of 29 evidence-based quality measures. The California BCCTP group scored higher than the registry cohort in four out of five domains (diagnostics, surgical and adjuvant care, toxicity management); it scored lower in follow up surveillance (mammograms). Overall, these are generally positive findings.  However, they are limited to California, and results may not be generalizable to other states.

First, a word about measures: the California BCCTP study used a series of 29 evidence-based measures developed by the National Initiative for Cancer Care Quality to evaluate the care of women with early stage breast cancer in the hospital registry cohort, which served as the benchmark. These are process measures; that is, they gauge the extent to which care provided is based on adherence to existing evidence-based guidelines and recommendations. While obviously a critical component of quality, process measures do not capture the full measure of quality care. For this we need outcome measures – survival data.

The California BCCTP study is important for a number of reasons. Results demonstrate adherence to evidence-based diagnostic and treatment recommendations, in contrast with previous limited data that suggest Medicaid coverage is generally associated with lesser quality care. Findings highlight areas where providing information to patients in care decisions (breast-conserving surgery, mastectomy, reconstruction) could benefit patients and result in higher quality care. Women in the California BCCTP were more likely to be younger, from minority populations and at lower educational levels than those in the cohort. They also generally presented with later stage disease compared with the cohort, and had a higher rate of recurrence within the 36 months that patients were enrolled in the program, underscoring the challenges in obtaining timely diagnosis in an uninsured population, despite the availability of the breast and cervical cancer screening and treatment programs. Despite the fact that the Breast and Cervical Cancer Treatment Program provides critical evidence-based care to uninsured women, we need health policies that provide comprehensive quality health care on a regular basis (versus disease-specific programs) to overcome barriers and disparities.

-Carol Matyka, 1998 Project LEAD®, 2001 Clinical Trials Project LEAD®, 2004 Quality Care Project LEAD®

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