Impact of Medicaid Expansion on Pancreatic Adenocarcinoma Survival in the Southern US

Background: The Affordable Care Act and the Recalcitrant Cancer Research Act are health policies that can impact cancer survival. Of the ten states that did not adopt Medicaid expansion, seven are in the South. Herein, we examine these policies' impact on pancreatic cancer treatment and survival. Study Design: The National Cancer Database was utilized, identifying patients with pancreatic adenocarcinoma between 2008 to 2022. Trend analysis was conducted to evaluate changes in treatment over time. Survival analysis and logistic regression were utilized. Results: The rate of pancreatectomy remained stable: 2008-2012:19.7%; 2013-2017:20.5%; 2018-2022:19.8%(Cochran-Armitage Trend test:p=0.96). Median survival for surgical patients significantly increased: 20.7 months in 2008-2012 versus 25.6 and 31.1 months in 2013-2017 and 2018-2021, respectively (Log-rank:p<.0001). Systemic therapy utilization significantly increased: 68.9% in 2008-2012 versus 76.7% in 2013-2017 and 83.1% in 2018-2022(Cochran-Armitage:p<.0001). The overall survival(OS) was worse in the South, 23.7 months compared to 29.3, 26.3, and 25.3 months in the Northeast, West, and Midwest, respectively (Log-Rank:p<.0001). After adjusting for factors associated with survival, limited Medicaid expansion was associated with worse OS (HR: 1.12, 95%CI:1.07-1.17,p<.0001). Multivariable analysis showed that patients treated in the Midwest(OR:1.46, 95%CI:1.39-1.54), Northeast(OR:1.27, 95%CI:1.20-1.34), and West(OR:1.14, 95%CI:1.08-1.21) had higher odds of receiving systemic therapy compared to the South. Conclusions: Although the rate of pancreatectomy did not change, the OS significantly improved during the study period, likely due to the increased utilization of systemic therapy. Patients in the South of the US had worse OS and lower odds of receiving systemic therapy, suggesting that limited Medicaid expansion police could have driven these outcomes.