138 - State Paid Family Leave Policies, Informal Family Caregivers and Cancer Mortality among Older Adults

Purpose/Objective(s): Home care for older adults with cancer often is performed by informal family caregivers, who may require substantial time away from work. Several states have implemented mandatory paid family leave policies, whereby qualified working individuals gain several weeks of paid time off to tend for family members requiring medical care, which we hypothesized may improve outcomes for their older family members with cancer. We previously reported associations for all cancers combined; here we focus on associations by leading cancer sites.

Materials/Methods: State-level cancer mortality data from 2003 –2021 for adults ages =75 years were obtained by age and year and leading cancer site through the National Vital Statistics System. We focused on adults =75 years as they are more likely to not work and require assistance. Leading cancer sites were defined as the top 5 leading causes of cancer death. Difference-in-differences (DID) analyses were utilized to compare changes in cancer mortality rates from pre- to post-policy implementation between states that did (DC, NJ, NY, RI, WA) and did not (CO, DE, ME, MD, OR) enact mandatory paid family leave policies during the study period. Comparison states were limited to the states that eventually enacted mandatory paid family leave policies after 2021. Analyses accounted for state and year fixed effects; Medicaid expansion; and state-level % unemployment, % high school completion, % poverty, % insured, and % non-Hispanic White. Generalized estimating equations with clustering by state were utilized to account for correlations in mortality rates over time within states. Event-study analyses evaluated the plausibility of the parallel trends assumption. Sensitivity analyses utilized comparison groups of geographically similar states as well as included states with voluntary paid family leave policies.

Results: A total of 190 state-year units for each cancer site were available for analysis. There were 129 (breast), 123 (colorectal), 305 (lung), 89 (pancreas), and 261 (prostate) cancer deaths per 100,000 in this cohort. In adjusted DID analyses, state mandatory paid family leave was associated with a modest decrease in mortality from breast (OR 0.94, 95% CI = 0.90 - 0.98, P=.006), colorectal (OR 0.92, 95% CI = 0.89 - 0.96, P<.001), and lung cancers (OR 0.96, 95% CI = 0.92 – 1.00, P=.029), with less evidence for an association for prostate cancer (OR 0.93, 95% CI = 0.87 - 1.00, P=.057), and minimal changes for pancreas cancer (OR 0.98, 95% CI = 0.94 - 1.02, P=.30). Sensitivity analyses showed consistent findings for breast and colorectal cancers. These estimates translate to 1000 fewer breast and 1300 fewer colorectal cancer deaths after policy implementation.

Conclusion: State mandatory paid family leave was associated with decreased cancer mortality among older adults, particularly breast and colorectal cancer mortality. Policies supporting working caregivers’ ability to devote time to care for older family members with cancer may improve cancer outcomes.