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Study finds significant screening disruptions at FQHCs

Our NFL-funded project is helping health centers catch up.

A new study finds that the COVID-19 pandemic contributed to significant disruptions in breast, colorectal, and cervical cancer screenings among federally qualified health systems, spanning 15 states across the U.S. Among its authors is Marcie Fisher-Borne, PhD, MPH, MSW, managing director, Interventions & Implementation, for ACS. (Click here to watch Dr. Fisher-Borne talk about the study.)

The postponed screenings have created backlogs that systems will need to address as health facilities re-open for preventive care, according to the study. Data were collected in August-September 2020, and the study was also published in the Journal of Preventive Medicine.

Of the 22 systems in the study, 11 (50%) reported stopping cancer screening completely for the cancer type specified in their application since the start of COVID-19 disruptions. One center reported never stopping screening entirely for their specified cancer types. Over half of all systems reported enforced screening service disruptions/cancellations as a result of state or local COVID-19 restrictions. 

The Cancer Screening during COVID-19 projects aim to help FQHCs resume cancer prevention services and catch up on missed cancer screenings to mitigate the impact of disruptions in care related to COVID-19 on cancer morbidity and mortality.

The study shows that when clinics were asked about service disruption, there was not one unified picture, and different clinics even within the same state described different times when experiencing peaks in disruption of screening. Half of the systems were able to maintain home-based stool sampling testing for colorectal cancer without any disruptions. The study also found that 100% of the clinics switched to telehealth visits, and 100% implemented structural changes in the office, including waiting room protocols. 

In 2020, the ACS and the National Football League (NFL) joined forces to offer a new funding opportunity called Cancer Screening during COVID-19, aimed at reducing cancer mortality disparities and alleviating the additional strain COVID-19 put on Federally Qualified Health Centers (FHQC). The NFL-funded program supports FHQCs' efforts to resume high-quality screenings for breast, cervical, and colorectal cancer, catch up on missed screenings, and provide timely follow-up care. In the long-term, these projects seek to address the known disparities in cancer incidence and mortality and challenges with limited access to specialty care in under-resourced communities.

“Without purposeful intervention, pandemic-related disruptions in preventive services may widen existing cancer disparities,” the authors write. “That is why partnerships like our COVID recovery screening project are critical, and ACS is honored to work with FQHCs to get back on track with screening.



  • Study: 4% of all new cancers in 2020 may be linked to alcohol

    Authors call for greater public awareness of  link between alcohol and cancers.

    A new study led by scientists from the International Agency for Research on Cancer (IARC) shows that an estimated 741,000 new cases of cancer in 2020 were associated with alcohol consumption globally.

    These latest data, published July 14 in The Lancet Oncology, indicate that although risky and heavy drinking patterns (more than two alcoholic drinks per day) represented the largest cancer burden (86% of the total alcohol-attributable cases), light to moderate drinking (up to two alcoholic drinks per day) represented 1 in 7 alcohol-attributable cases and accounted for more than 100,000 new cancer cases worldwide.

    “Alcohol consumption causes a substantial burden of cancer globally,” said Dr. Isabelle Soerjomataram, deputy head of the Cancer Surveillance Branch at IARC. “Yet the impact on cancers is often unknown or overlooked. This highlights the need for implementation of effective policy and interventions to increase public awareness of the link between alcohol consumption and cancer risk, and to decrease overall alcohol consumption to prevent the burden of alcohol-attributable cancers.”

    Our own Farhad Islami, MD, PhD, scientific director, Cancer Disparity Research (pictured here), was one of the 10 researchers that were involved in the design and conduct of this study. He noted that "the results for the U.S. are consistent with findings of our previous studies at the ACS and further support prioritizing federal- and state-level cancer prevention and control efforts to reduce alcohol consumption and the burden of alcohol-related cancers.” 

    All the results of the IARC study are available on the new Cancers Attributable to Alcohol website, which is part of the Cancer Causes subsite of the IARC Global Cancer Observatory. The database has user-friendly facilities to produce maps and explore visualizations of the global burden of cancer attributable to alcohol consumption by sex, cancer site, and country or world region.

    Here are some key findings:

    • Eastern Asia and Central and Eastern Europe regions had the highest proportions of cancer cases that could be associated with alcohol at 6%, with the lowest proportions found in Northern Africa and Western Asia, both below 1%.
    • The study estimates that men accounted for 77% (568,700 cases) of alcohol-associated cancer cases, compared with women, who accounted for 23% of cases (172,600). 
    • Cancers of the esophagus (189,700 cases), liver (154,700 cases), and breast (98,300 cases) accounted for the largest number of new cases, followed by colorectal cancers and cancers of the mouth and throat. 
    • Among women, the largest proportions of cancer cases that were attributed to alcohol were estimated to be in the regions of Central and Eastern Europe (3%, 21,500 cases), and Australia and New Zealand (3%, 2,600 cases). Amongst men, the largest proportions of cancer cases linked to alcohol were found in Eastern Asia (9%, 275,900 cases) and Central and Eastern Europe (8%, 49,900 cases).
    • At a country level, the proportions of cancer cases associated with alcohol were estimated to be highest in Mongolia (10%, 560 cases) and lowest in Kuwait (estimated at 0%, less than 5 cases). The UK had an estimated 4% of cancer cases linked to alcohol (16,800), with the United States at 3% (52,700), Brazil at 4% (20,500 cases), India at 5% (62,100), China 6% (282,300), Germany 4% (21,500 cases) and France at 5% (20,000 cases - see Appendix table 4 for country level data).

    Alcohol consumption has been shown to cause DNA damage through increased production of harmful chemicals in the body, and affect hormone production, which can contribute to cancer development. Alcohol can also worsen the cancer-causing effects of other substances, such as tobacco.

    Public health strategies, such as reduced alcohol availability, labelling alcohol products with a health warning, and marketing bans could reduce rates of alcohol-driven cancer, the authors say. Tax and pricing policies have led to decreased alcohol intake in Europe.

    Trends suggest that although there is a decrease in alcohol consumption per person in many European countries, alcohol use is on the rise in Asian countries such as China and India, and in sub-Saharan Africa. In addition, there is evidence that the COVID-19 pandemic has increased rates of drinking in some countries.

    There are several limitations to the study, including the potential effect of the COVID-19 pandemic, which has impacted behaviors including alcohol drinking and also cancer services in many countries and could have affected cancer risks and diagnosis rates. Further, the main study analysis did not take into account former drinking, or any relationships between tobacco or obesity with alcohol, which could have attributed some cases to alcohol that were actually driven by, for example, smoking. 

    Professor Amy C. Justice, Yale University, (who was not involved in the study), notes that estimating the effects of alcohol intake on cancer rates across countries is notoriously difficult. She writes that a quarter of alcohol purchases are not captured by government data, making it difficult to estimate accurate sales figures. "Until we address limitations in measurement, we might be underestimating health risks, especially cancer risks, associated with alcohol," she said.

    Read the full study.


  • Cancer death rates continue to drop, but the news is not all good

    Overall incidence rates continue to increase in women, children, and adolescents and young adults.

    Overall cancer death rates continue to decline in men and women for all racial and ethnic groups in the U.S., according to the latest Annual Report to the Nation on the Status of Cancer published on July 8.

    During 2001 to 2018, declines in lung cancer death rates accelerated, and death rates for melanoma declined considerably in more recent years, reflecting a substantial increase in survival for metastatic melanoma. However, the report finds that for several other major cancers, including prostate, colorectal, and female breast cancers, previous declining trends in death rates slowed or disappeared. 

    The report published in the Journal of the National Cancer Institute also finds that overall cancer incidence rates continue to increase among females, children, and adolescents and young adults (AYA). All trends in this report cover the period before the COVID-19 pandemic.

    The annual report is a collaborative effort among the American Cancer Society (ACS); the Centers for Disease Control and Prevention (CDC); the National Cancer Institute (NCI), part of the National Institutes of Health (NIH); and the North American Association of Central Cancer Registries (NAACCR).  

    The report shows a decrease in death rates for 11 of the 19 most common cancers among men, and for 14 of the 20 most common cancers among women, over the most recent period (2014-2018). Although declining trends in death rates accelerated for lung cancer and melanoma over this period, previous declining trends for colorectal and female breast cancer death rates slowed, and those for prostate cancer leveled off. Death rates increased for brain and other nervous system cancers, as well as pancreas cancer, in both sexes; oral cavity and pharynx in males, and liver and uterus in females.

    “The declines in lung cancer and melanoma death rates are the result of progress across the entire cancer continuum - from reduced smoking rates to prevent cancer to discoveries such as targeted drug therapies and immune checkpoint inhibitors,” said ACS CEO Karen E. Knudsen, MBA, PhD. “While we celebrate the progress, we must remain committed to research, patient support, and advocacy to make even greater progress to improve the lives of cancer patients and their families.”

    An analysis of long-term trends in cancer death rates in this year’s report also shows that death rate declines accelerated in both males and females from 2001 to 2018. In males, a decline of 1.8% per year in 2001 to 2015 accelerated to a decline of 2.3% per year during 2015 to 2018. In females, a decline of 1.4% per year from 2001 to 2015 accelerated to a decline of 2.1% per year during 2015 to 2018. The report found that overall cancer death rates decreased in every racial and ethnic group during 2014 to 2018.

    “It is encouraging to see a continued decline in death rates for many of the common cancers,” said Karen Hacker, MD, MPH, director of CDC’s National Center for Chronic Disease Prevention and Health Promotion. “To dismantle existing health disparities and give everyone the opportunity to be as healthy as possible, we must continue to find innovative ways to reach people across the cancer care continuum—from screening and early detection to treatment and support for survivors.”

    However, increases in cancer incidence and death rates or deceleration of previous declining trends for some other cancers such as colorectal and female breast cancers are likely due to risk factors such as obesity.   

    “The continued decline in cancer death rates should be gratifying to the cancer research community, as evidence that scientific advances over several decades are making a real difference in outcomes at the population level,” said Norman E. “Ned” Sharpless, MD, director of the National Cancer Institute, of the National Institutes of Health. “I believe we could achieve even further improvements if we address obesity, which has the potential to overtake tobacco use to become the leading modifiable factor associated with cancer.” 

    The authors report that cancer death rates continued to decrease among children (aged <15 years) and AYAs (aged 15-39 years) despite an increase in incidence rates from 2001 to 2017. Overall cancer incidence rates in children and AYA increased in all racial/ethnic groups except American Indian/Alaska Native (AI/AN) children, where rates remained stable. The most common cancer among AYA was female breast cancer. 

    “When evaluating health disparities, it is critical to acknowledge the social factors that influence the health of the communities and access to health care,” said Betsy A. Kohler, MPH, NAACCR executive director. “Social and economic indicators, particularly based on small area assessments, are increasingly important to understanding the burden of cancer.”

    Other key findings include:  

    • Overall cancer incidence rates were higher among men than women in every racial and ethnic group, except Asian/Pacific Islander population, where the rates were similar. 
    • Overall cancer incidence rates were slightly lower among Black people than White people. 
    • In contrast, overall cancer death rates were higher among Black people than White people.  
    • Incidence rates of liver cancer were previously increasing, but data show rates have stabilized among both men and women. 
    • Two-year relative survival for advanced-stage melanoma cases diagnosed during 2001-2009 was stable, but it increased 3.1% per year for those diagnosed during 2009-2014.
    • Two-year relative survival only slightly increased for early- and intermediate-stage melanoma cases diagnosed during 2001-2014 (0.03% and 0.4% per year, respectively).

    The authors indicate these findings can help inform healthcare providers about the need to increase efforts related to cancer prevention, early detection, and treatment, and for the need for equitable implementation of effective interventions, especially among under-resourced populations.

    Article: Annual Report to the Nation on the Status of Cancer, Part I: National Cancer Statistics. JNCI: The Journal of the National Cancer Institute. doi: 10.1093/jnci/djab131.


  • ACS names diversity research grant for Reggie Minton

    Minton was NABC's liaison for Coaches vs. Cancer for 28 years.

    The American Cancer Society is celebrating the retirement of Reggie Minton (pictured here), the National Association of Basketball Coaches (NABC) liaison for Coaches vs. Cancer for the past 28 years, by establishing the Reggie Minton Diversity in Cancer Research Internship Grants Fund.

    The single grant that will be named in his honor will support the Society’s broader Diversity in Cancer Research Internship grant program, and it was unveiled as NABC Coaches gathered for the Coaches vs. Cancer Circle of Honor Dinner this month in Wisconsin.

    “Throughout his career, Reggie Minton was a tireless supporter of the life-saving work of Coaches vs. Cancer and a staunch advocate for the cause of diversity and inclusion,” said Craig Robinson, NABC executive director. “The American Cancer Society Reggie Minton Diversity in Cancer Research Internship Grants bring together those two passions and are a fitting tribute to Reggie’s legacy.”

    High-quality research requires a research community comprised of people with unique perspectives and contrasting experiences. To help improve inclusion and diversity in the scientific community, the Society is launching this inaugural internship fund to engage undergraduate students of diverse backgrounds in hands-on cancer research and provide career development support in the hopes they will pursue a career in research.

    By providing the opportunity to pursue cancer research as a career, this internship fund will make a direct and potentially life altering impact on dozens of undergraduate students’ lives.

    Initial funding for the internship fund, totaling $350,000, was provided by Sanford Health and an anonymous donor. 

    If people are interested in helping to secure additional funding or would like to make an investment in honor of Reggie Minton, please contact Natalie Morrison at natalie.morrison@cancer.org.


  • Bravo! Our journals’ impact scores are in . . .

    . . . and they deserve a standing ovation! 👏👏👏

    The annual scientific and clinical Journal Impact Factors were released on June 30, and to say that our journal CA: A Cancer Journal for Clinicians outperformed is a vast understatement. 

    While not a surprise, it's certainly welcome news. CA is not only the leading journal for the entire oncology subject category but ranks highest for all 254 categories included in the Web of Science (clarivate.com)

    CA’s score is due mainly to the global cancer statistics article and the annual report on cancer statistics, two of the most cited cancer articles in the world. These citations, factored along with a small number of publications, accounts for CA’s high score. Other highly cited manuscripts include the ACS screening guidelines, cancer statistics for special populations, and comprehensive reviews. You can find them here.

    Our journal Cancer Cytopathology ranked No. 1 in the field of cytopathology. It scored 5.284. Our journal Cancer scored 6.860. Each journal falls within the top quartile of its subject category. 

    Below is a list of top 10 rankings for all oncology titles for 2018 and 2019, according to Clarivate: 

    Journal name

    Total Citations

    2020 Journal Impact Factor (JIF)

    CA-A CANCER JOURNAL FOR CLINICIANS

    55,868

    508.702

    Nature Reviews Clinical Oncology

    17,973

    66.675

    NATURE REVIEWS CANCER

    62,391

    60.716

    JOURNAL OF CLINICAL ONCOLOGY

    189,443

    44.544

    LANCET ONCOLOGY

    72,804

    41.316

    Cancer Discovery

    27,030

    39.397

    ANNALS OF ONCOLOGY

    61,542

    32.976

    JAMA Oncology

    22,382

    31.777

    CANCER CELL

    50,839

    31.743

    Molecular Cancer

    24,931

    27.401


    Bill Cance, MD, our chief medical and scientific officer, is editor in chief of CA: A Cancer Journal for Clinicians, and Ted Gansler, MD, MBA, MPH, is its editor. 

    It should be noted that this year's statistics show inflated scores across all titles due to a new calculation method used by Clarivate, but the scores are all relative and it does not diminish our standings.


  • Study: Pandemic adversely affected cancer detection and surgical treatments

    Greatest declines in detection were seen in lung (17.4%) and colorectal (12.0%) cancers.

    A new study finds evidence for adverse effects of the COVID-19 pandemic on declines in cancer detection and surgical treatments. The study, appearing in JNCI: The Journal of the National Cancer Institutefinds a 10.2% decline in real-time electronic pathology reports from population-based cancer registries in 2020 compared with those in 2019.

    This study observation period, through December 2020, is one of the longest to date for evaluating the effects of the COVID-19 pandemic on cancer-related trends. To learn more about the indirect effects of the pandemic on cancer care, investigators led by Robin Yabroff (pictured here), PhD, MBA, used electronic pathology data from population-based SEER cancer registries from Georgia and Louisiana that included information about cancers from all age groups. Trends for breast, colorectal, lung, and prostate cancers, the most common cancers, were assessed separately, as were trends by age group.

    The study found initial patterns of declines were generally like those reported elsewhere, with greatest differences in April 2020 relative to April 2019, the first peak in COVID-19 mortality rates in Georgia and Louisiana. Declines in pathology reports in August, November, and December coincided with later peaks in COVID-19 mortality rates.  

    “We observed substantial declines in 2020 among cancers with effective screening tests, including breast and colorectal cancers, as well as across cancer sites and age groups without effective screening tests, including cancers among children and young adults,” said Robin. “Declines across cancer sites and age groups suggest that in addition to delays in cancer screening, there were also delays in routine well-child and primary care, evaluation of signs and symptoms, and treatment initiation for most cancers.”

    Notably, the number of pathology reports in 2020 never consistently exceed those in 2019 after initial declines, which might be expected if a backlog of diagnoses were being resolved. By cancer type, percentage declines were greatest for lung (17.4%) and colorectal (12.0%) cancers, followed by breast (9.0%) and prostate (5.8%) cancers. Declines were observed in all age groups, including children and adolescents younger than 18 years. Patterns of declines were similar by cancer site and age group, with some variation in timing, magnitude, and duration of declines.   

    “The findings suggest substantial delays in diagnosis and treatment services for cancers during the pandemic, and that ongoing evaluation can inform public health efforts to minimize any lasting adverse effects of the pandemic on cancer diagnosis, stage, treatment, and survival,” write the authors. “As data become available, evaluation of the effects of the pandemic on cancer stage at diagnosis and survival will be important, as will evaluation of racial/ethnic, socioeconomic, and geographic disparities in access to care and outcomes.”  

    Article: Yabroff KR, Wu XC, Negoita S, Stevens J, Coyle L, Zhao J, Mumphrey B, Jemal A, Ward K. Association of the COVID-19 Pandemic with Patterns of Statewide Cancer Services. JNCI: Journal of the National Cancer Institute, 2021. doi: 10.1093/jnci/djab122.


  • ACS National Consortium hosts first Issue Hub

    ​300 attendees learn how to boost cancer screening rates.

    As part of our comprehensive effort to increase cancer screening rates, we launched a national consortium this spring to engage a diverse and influential group of leaders. 

    On June 1, the consortium welcomed over 300 attendees to participate on our inaugural Issue Hub titled “Accelerating What We Know Works in Cancer Screening and Care.” National Consortium Issue Hubs are facilitated panel discussions with renowned subject matter experts who are challenged to identify, deliberate, and build consensus around the most pressing issues in the recovery and improvement of cancer screening and care nationwide. 

    This was the first of three planned Issue Hubs this year.

    This session explored key areas of national alignment in the implementation of evidence-based and emerging cancer screening activities. Moreover, the information gathered during this Issue Hub is critical to the future conversations and decision-making of the National Consortium. 

    The panel for this Issue Hub reflected the level of thought-leaders and influential voices we hope to continue gathering around our virtual table. Panelists included:        

    • Keysha Brooks-Coley, MA – vice president, Federal Advocacy and Strategic Alliances, ACS CAN
    • Timothy Mullet, MD, FACS – chair, Commission on Cancer of the American College of Surgeons
    • Lisa Richardson, MD, MPH – director, Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC
    • Robert Smith, PhD – senior vice president, Cancer Screening, ACS
    • John Williams, MD, FACS – chair, President’s Cancer Panel
    • Discussion Lead: Rich Wender, MD –  chair, Family Medicine and Community Health University of Pennsylvania; chair, National Colorectal Cancer Roundtable

    Throughout the 90-minute session, panelists shared their best thinking on:

    • The factors, big and small, that prevent us from seeing the outcomes we want to see in cancer screening and care.
    • How to accelerate adoption of proven cancer screening and care activities to reach our desired outcomes.
    • The innovations or opportunities necessitated by the pandemic that we could leverage to expand our capacity in cancer screening and care.

    Attendees were invited to engage via virtual meeting tools, including live polling and idea boards. 

    The National Consortium’s next Issue Hubs are tentatively scheduled for August and November. Panelists will rotate so that stakeholders around the country can listen to, learn from, and ideate with a variety of public health leaders, researchers, clinicians, and other thought leaders.  

    Early survey results indicate an appetite for participation on these events: 

    • 97% thought the overall session was excellent or good
    • 99% would like to attend another Issue Hub
    • 97% would like to stay connected with the National Consortium efforts
    • 94% would recommend attending an Issue Hub to a colleague 
    • 92% learned something new and 91% learned something they would consider valuable

    National Consortium members will reconvene on June 17 in a virtual summit to further consider the discussion of our first Issue Hub and look to provide actionable recommendations which are necessary to not just accelerate our recovery from the pandemic, but also accelerate our resilience and overall improvement in providing quality cancer screening and care for all. 

    A recording of the June Issue Hub is available here. A summary report of the Issue Hub will be made available by June 18. For questions about the consortium, contact Sarah Shafir or Caleb Level. View a list of the consortium members.

    About ACS’s National Consortium

    ACS and ACS CAN have organized mission priorities and program work to effectively respond to consequences from the COVID-19 pandemic on cancer screening and care. The National Consortium, which focuses on accelerating, strengthening, and mobilizing, is one component of this initiative. It is an issue-focused, time-bound partnership that is dedicated to the acceleration of a national response to the COVID-19 pandemic in relation to its detrimental impact on our collective progress in cancer screening and care across the U.S. Our overall return to screening effort is supported by Genentech, Pfizer, Merck, and the National Football League. 


  • NCI showcases ACS Senior Scientific Director Rebecca Siegel’s CRC research

    This year marks the 50th anniversary of the National Cancer Act of 1971, which created a national commitment to making progress against cancer. The law established the National Cancer Institute (NCI) in its current form and represented the US’s commitment to the “war on cancer,” as then-President Nixon described it.

    To highlight progress against cancer since the law’s inception, the National Cancer Institute this year is sharing groundbreaking developments in cancer research. One of the brilliant scientists featured on their website right now is our own Rebecca Siegel, MPH, senior scientific director, Surveillance Research.

    The article shares how Becky examined data from the NCI’s SEER program and other cancer databases to uncover an increase in the number of people under 50 being diagnosed with colorectal cancer, which led ACS to lower our CRC screening age from 50 to 45 in 2018, no doubt saving countless lives. The USPSTF just followed suit last month, joining ACS in recommending people at average risk begin screening for CRC at age 45.

    Congrats to Becky on this well-deserved recognition! This is a terrific example of the kind of research and innovation ACS is known for. Be sure to check out the story – it’s a great read!


  • Study underscores dangers of insurance disruption

    Lack of coverage consistently associated with worse healthcare access.

    A new study underscores the importance of health insurance coverage continuity in access to and receipt of care and care affordability in the U.S. Researchers found that health insurance coverage disruptions were consistently associated with worse healthcare access and problems with care affordability. The study appears in the American Journal of Preventive Medicine

    Decades of research has demonstrated that health insurance coverage is associated with better access to care and health outcomes in the U.S. However, less research has addressed coverage disruptions (i.e., periods without insurance) among adults with current coverage and the relationship of disruptions to care access, receipt of recommended preventive services, and affordability. To learn more, investigators led by Robin Yabroff (pictured here), PhD, MBA, our scientific VP, Health Services Research, conducted a comprehensive examination of insurance coverage disruptions among adults aged 18 to 64 years from the 2011-2018 National Health Interview Survey using multiple measures of access and affordability, and evaluated the effects of the duration of coverage disruption among currently insured and uninsured.  

    The study found that prior disruptions in insurance coverage were relatively common among adults aged 18-64 years. Among currently insured adults, 5.0% with private insurance and 10.7% with public insurance reported a coverage disruption in the prior year, representing nearly 9.1 million adults in 2018. Among currently uninsured adults, 24.9% reported coverage loss within the prior year, representing nearly 8.1 million adults in 2018. Compared to adults with continuous health insurance coverage, adults with coverage disruptions were less likely to receive recommended preventive services and more likely to forgo any needed care because of cost and report medication non-adherence because of cost.  

    Longer coverage disruptions were associated with worse care access and affordability. The magnitude of associations between coverage disruptions and care access and affordability was similar among adults with either current private or current public coverage. Currently uninsured adults, especially with longer uninsured periods, reported significantly worse care access, receipt, and affordability than currently insured adults with coverage disruptions or continuous coverage.  

    “Our findings highlight the importance of health insurance coverage continuity related to access to care and affordability. This is especially relevant with recent increases in unemployment due to the COVID-19 pandemic and widespread loss of employer-based private coverage, the primary source of private coverage in the working-age population,” said the authors. 

    Article: Yabroff R, Zhao, J, Halpern M, Fedewa S, Han X, Nogueira L, Zheng Z, Jemal A. Health insurance disruptions and care access and affordability in the US. AJPM: American Journal of Preventive Medicine, 2021. doi: 0.1016/j.amepre.2021.02.014. 


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