Changes in prostate-specific antigen at the time of prostate cancer diagnosis after medicaid expansion in young men

Background The objective of this study was to determine the effect of Medicaid expansion under the Patient Protection and Affordable Care Act (January 1, 2014) on the epidemiology of high-risk prostate-specific antigen (PSA) levels (>= 20 ng/mL) at the time of prostate cancer (PCa) diagnosis. The authors hypothesized that better access to care would result in a reduction of high-risk features at diagnosis. Methods A retrospective cohort study was performed of 122,324 men aged <65 years who were diagnosed with PCa within the National Cancer Database. Difference-in-difference (DID) analyses adjusting for sociodemographic variables using linear regression compared PSA levels at diagnosis before expansion (2012-2013) and after expansion (2015-2016) between men residing in states that did or did not expand Medicaid. Results From 2012 to 2016, the proportion of men with PSA levels >= 20 ng/mL increased (from 18.9% to 19.8%) in nonexpansion states and decreased (from 19.9% to 18.2%) in expansion states. Compared with men in nonexpansion states, men in expansion states experienced a decline in PSA >= 20 ng/mL (DID, -2.33%; 95% CI, -3.21% to -1.44%; P < .001). Accordingly, the proportion of men presenting with high-risk disease decreased in expansion states relative to nonexpansion states (DID, -1.25%; 95% CI, -2.26% to 0.25%; P = .015). A similar statistically significant decrease in PSA levels >= 20 ng/mL was noted among black men (DID, -3.11%; 95% CI, -5.25% to 0.96%; P = .005). Conclusions In Medicaid expansion states, there was an associated decrease in the proportion of young men presenting with PSA >= 20 ng/mL at the time of PCa diagnosis. These results suggest that Medicaid expansion improved access to PCa screening. Longer term data should assess oncologic outcomes.